Dental Sleep Practice Spring 2021 by MedMark, LLC

How Do Dentists Tackle the

54-million-pound Elephant Called Sleep Apnea? by David Schwartz, DDS, D.ABDSM

Better Sleep Breathing Requires Better Tools by Len Liptak, MBA, Mark T. Murphy, DDS, D.ABDSM, and Keith Batcheller, BS, MA

SPRING 2021 | dentalsleeppractice.com

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INTRODUCTION

Finding Perspective; Billy Joel in New Orleans

’m writing this from New Orleans, one of our nation’s most lively, energetic, and resilient cities. I also spent time here back in early March 2020 B.C. (Before COVID). I was here a few months ago in October of 2020, too. It’s different now. That’s for sure. There are obvious physical signs such as masks and the omnipresent notices on doors as if anyone needed reminders about social distancing and safety mandates. There’s other evidence as well. The crowds are a tiny fraction of what they once were, and restaurant capacity is severely limited with tables staggered every 4 sidewalk squares or so. Also, no one is throwing beads from balconies, but if they did, they’d likely chant, “Show your face, show your face!” Uninhibited bachelorette party revelers could then briefly lower their N95s. See, New Orleans IS for families. How do I know this? Because I see it when I go for daily runs in a mask through a changing landscape of partially drunk, mostly clothed, fully masked revelers. Listen, it’s different. It is. But it’s moving in the right direction. Not only is the city looking more like itself, but it’s looking like an adaptive, evolving better version of its B.C self. Bars are constructing curbside open-air structures thanks to expedited regulatory approval from a city government that’s known for its graft-addled morass. Minus the graft, beads, and beer, I posit your practice is similar. Sure, you have to place increased emphasis on protective gear. Is that a bad thing? Your patient doesn’t have to drive 90 minutes for an appliance check and you get to do a consultation from home in a sweater and sweatpants. It could be worse, right? Note that I said, “get to” rather than “have to.” It’s perspective, my friends. You can’t control the restaurant opening guidelines that seem to be in a perpetual state of flux or the EEOC’s confounding guidance about bringing employees back. Those are exogenous factors.

Perspective – how you THINK of this situation is the only thing over which you truly have agency, and there your authority is complete. You can’t control the virus, the openings, or the political climate any more than you can change the weather. What you can alter is how you Jason Tierney think of it and what right action you take. Is this an opportunity where you get to do telemedicine or have to? Soon enough you’ll complain about the commute to the office. Is it a chance to spend more time with your family since you aren’t working 53 hours per week? In the near future, time will The good ol’ days be a scarce resource again and you’ll wonweren’t always so der how your kids got so big so fast. The losses of life and revenue have good and tomorrow been monumental. Fortunately, vaccines are ain’t as bad as it becoming more readily available. Dental seems. consumer confidence is high. We are in a better position than we were yesterday. Things will continue to change, but one thing is a constant truism; Sleep is necessary for life. It isn’t a choice. It’s not just a requirement for a life well lived. Without it, you will die. You can help people sleep. You can save lives. Sleep on that and get to work. Telemedicine, remote patient monitoring, focused marketing, improved appliance designs, and expedited regulatory approvals – these are just a few developments that rose to prominence due to COVID and will continue to propel the field forward. Leverage them and ride the wave. Don’t long for the way it was. It may have been good. It wasn’t great. To quote my favorite troubadour Billy Joel, “The good ol’ days weren’t always so good and tomorrow ain’t as bad as it seems.” Don’t just rebuild. Build anew. You can do this. You are doing this. Now. DentalSleepPractice.com

CONTENTS

Cover Story

Better Sleep Breathing Requires Better Tools

by Len Liptak, MBA, Mark T. Murphy, DDS, D.ABDSM, and Keith Batcheller, BS, MA

The long-awaited ProSomnus EVO has arrived. Here’s everything you need to know about this (r)evolutionary new oral appliance’s future forward.

Continuing Education

Oral Appliance Therapy; The Definition of Effectiveness by John Viviano, DDS, D.ABDSM Everyone knows CPAP is more effective than OAT. Everyone is wrong. Dr. Viviano examines the effectiveness equation in this eye-opening CE article.

2 CE CREDITS

Clinical Focus

How Do Dentists Tackle the 54-million-pound Elephant Called Sleep Apnea? by David Schwartz, DDS, D.ABDSM The AADSM president shares details about the organization’s updated position on Home Sleep Testing. What does this mean for you?

Practical Tips

DME: Durable Medical Equipment or Dental Medical Expertise?

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2 DSP | Spring 2021

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CONTENTS

Publisher’s Perspective

Renewed Energy in 2021 by Lisa Moler, Founder/CEO, MedMark Media

10 Expert View

In Your Own Words The AADSM has published a new position paper on HST. Read what changes these clinicians will make – In Their Own Words.

20 Bigger Picture

Here’s Your Productivity Hack: Go To Sleep by Ryan Holiday We live in a climate that praises constant hustle and we’re tethered to screens. That’s a good thing, right?

30 Clinical Focus

It is Time to Reëvaluate AHI’s Role in Decision Making by Barry Glassman, DMD, and Don Malizia, DDS Is it time to rethink the role of AHI in diagnosing and treating OSA?

34 Billing Blocks Remote Patient Monitoring Reimbursement – Medicare Leads But Will Private Payors Follow? by Randy Curran Remote patient monitoring is likely here to stay, but how do you bill for it?

40 Practice Management

Dental Marketing – Referrals Trump Everything by John Tucker, DMD, D.ABDSM, DICOI, and Elias Kalantzis The COVID bounceback requires savvy marketing. What’s the best approach to get more quality patients and keep them coming back?

4 DSP | Spring 2021

44 Pediatrics Face Facts: Function that Builds the Airway by Sharon Moore In part 3 of this 4 part series, Sharon Moore takes a closer look at dentistry’s role in addressing pediatric sleep disordered breathing.

48 Education Spotlight

Dental Sleep Medicine Education at Tufts University by Leopoldo Correa, BDS, MS, D.ABDSM Dental sleep education opportunities abound, but this one is unique.

50 Education Spotlight

One Investment Guaranteed to Pay Dividends by Samuel Cress, DDS What investment saves lives and boosts production? Dr. Cress provides the answer.

52 Company Spotlight

Who We Are: 3DISC 3DISC – The who, what, and why behind this powerhouse.

53 Book Review

Spring 2021 Publisher | Lisa Moler lmoler@medmarkmedia.com Editor in Chief | Jason Tierney jason@medmarkmedia.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com Editorial Advisors Jagdeep Bijwadia, MD Randy Clare Scott Craig Randy Curran Barry Glassman, DMD Elias Kalantzis Steve Lamberg, DDS, D.ABDSM Mayoor Patel, DDS, MS, RPSGT, D.ABDSM Mark Murphy, DDS John Viviano, DDS

Director of Operations Don Gardner | don@medmarkmedia.com Manager – Client Services/Sales Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com

Breath: The New Science of a Lost Art

eMedia Coordinator Michelle Britzius | emedia@medmarkmedia.com

Review by Steve Carstensen, DDS James Nestor’s new book has focused global attention on how we breathe. What does a DSM guru think of it?

Webmaster Mike Campbell | webmaster@medmarkmedia.com

54 Communications A Recipe for Success: Have the Right Conversation by Michael Cowen Which subtle communication shifts can you make for big gains in case acceptance?

56 Seek and Sleep DSP CodeWord

Social Media & PR Manager April Gutierrez | medmarkmedia@medmarkmedia.com

Front Office Administrator Melissa Minnick | melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $149 | 3 years (12 issues) $399 ©MedMark, LLC 2021. 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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PUBLISHER’Sperspective

Renewed Energy in 2021

o here we are in 2021. While the challenges of 2020 have not completely disappeared, we can definitely see healing and hope on the horizon. Personally, I am energized – looking forward to seeing all of you at in-person conferences and meetings, setting new goals, and finishing some that were put on hold.

Lisa Moler Founder/CEO, MedMark Media

What does this mean for MedMark and all of its publications? Since we thrive when you thrive, it means that we need you to share all of your thoughts with us. During the pandemic shutdowns, what ideas did you have for improving your office procedures and your clinical protocols when you returned? What are you doing to make those plans into actions? How are you focusing your renewed energy into more thriving practices? What were your challenges, and how are you going to make your practices more resistant to future forces that can get in the way of forward movement? We want to be the publication that brings you new techniques, cutting-edge technologies, innovative products, and articles that start conversations about how your dental talents can change lives for the better. Because of our readers, people overcome life-threatening sleep disorders, teenagers can smile without being self-conscious, and adults can obtain some orthodontic, implant, and endodontic treatments that weren’t even an option when they were teens. As we discover and spotlight new products and techniques, patients will not think of their dentist as just doing a root canal or implant but as being synonymous with healing and overall good health. In this issue of Dental Sleep Practice, we have a CE article on the effectiveness

of Oral Appliance Therapy compared to Positive Airway Pressure. This article offers insights into how physicians and dentists can work collaboratively to provide the best solution for individualized patient care. Our cover story discusses the ProSomnus® EVO™, a new FDA-cleared oral appliance medical device engineered to address the challenge for a better sleep breathing tool. This OAT uses patented and proprietary innovations to resolve many of the issues inherent in other appliances. Our Clinical Focus explores the AADSM’s position on home sleep apnea tests and how clinicians can use their training, common interactions with patients, and a collaborative model of care to be impactful and help medical colleagues and patients. These articles all have a common goal – uniting the profession in reducing the number of undiagnosed and untreated people with sleep apnea. We greet 2021 with so much hope, ideas, and energy. The MedMark team is ready to help you reach positive goals that exceed your expectations. With articles written by experienced and knowledgeable dental leaders and advertisements from technology and service leaders that involve all areas of dentistry, we aspire to be part of your healing, a source of your inspiration, and a vehicle for your success!

Do you like what you are reading in DSP? Do you have ideas you want to share about what works in your practice? Our editor Jason Tierney is happy to consider essays from any reader! Contact him at jason@medmarkmedia.com.

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CLINICALfocus

How Do Dentists Tackle the 54-million-pound Elephant Called Sleep Apnea? by David Schwartz, DDS, D.ABDSM

he last paragraph of the American Academy of Dental Sleep Medicine’s (AADSM) position statement on the scope of practice for dentists ordering or administering home sleep apnea tests (HSATs) is the most important point in my mind. “As health care providers who live by the ethical code of “do no harm” and understand the harmful consequences of OSA, we owe it to the public to implement models of care that reduce barriers to diagnosis and treatment, ensure that sleep apnea is diagnosed and treatment efficacy is verified by physicians, and maximize the training and skills of qualified dentists.”

8 DSP | Spring 2021

Would it be ideal for every patient in the country to have a face-to-face evaluation with a board-certified sleep medicine physician, have a polysomnogram, be presented with a variety of treatment options, get proper education on how to appropriately use their therapy, know who to contact when they have issues with their therapy and receive the appropriate follow-up care? Absolutely! And it’d be even better if all of this is done within seven to ten days. But the reality is that this is impossible – for a bevy of reasons – for most of the 54 million Americans with sleep apnea. The American Academy of Sleep Medicine (AASM) has acknowledged that there are too few board-certified sleep medicine physicians; approximately 5,700 throughout the country, many of whom are in metropolitan areas and affiliated with academic institutions, to manage the obstructive sleep apnea patient population. Primary care physicians (PCP) are stretched to their limits. Patients recognize how stretched PCPs are and often hesitate to raise concerns about things that may seem nonessential, such as concerns about their sleep. When the topic of sleep apnea is broached, PCPs do not always have access to the appropriate testing equipment. Fingers get pointed at insurers and government regulations for creating barriers. Rather than throw our hands up in the air, the AADSM has focused its efforts on how qualified dentists can help meet the burden of OSA. We believe that every patient with sleep apnea is entitled to effective treatment. Science is showing more and more every day the impact sleep apnea has on the overall health of Americans. If increased blood pressure, auto and workplace accidents, and heart disease weren’t enough, we now know that sleep apnea increases your likelihood of being hospitalized from COVID-19 and that there are some serious links between sleep apnea and Alzheimer’s. In a country where obesity continues to rise, we must ensure patients have access to diagnosis and treatment for sleep apnea. We must also recognize that patients are looking for resolution to their healthcare needs. Fragmented care and lengthy

CLINICALfocus wait times between screening and treatment cause people to ignore their health issues, especially when the consequences are more long term. Considering all of this, the AADSM created the HSAT position statement to outline a way we can play a role in solving these very real concerns. Using our training, common interactions with patients, and a collaborative model of care, we can be most impactful and help our medical colleagues and patients. This position statement makes it clear that the AADSM believes that: 1. It is within the scope of practice for a qualified dentist to order or administer HSATs. 2. Licensed medical providers should be diagnosing and verifying treatment efficacy. In this model, trained dentists complete an appropriate screening process which includes taking a medical and family history and also using validated screening tools and performing a physical exam. If patients are at risk and appropriate candidates for HSAT, a qualified dentist can order or administer the HSAT directly from his or her practice, assuming it is allowed by their state laws. Patients then complete the HSAT. Pertinent patient information and the HSAT data are provided to a physician for diagnosis, and, if appropriate, the physician prescribes an oral appliance. The qualified dentist then determines whether the patient is a suitable candidate, fabricates, and delivers the appliance. After the appliance is at the appropriate therapeutic position, the qualified dentist once again orders or administers an HSAT. Pertinent patient information and HSAT data are shared with the physician who verifies treatment efficacy. This model takes some burden off physicians. Trained dentists have a front seat view of our patients’ airways. Our appointment times allow us to incorporate conversations about sleep and a screening process into our workflows. This model requires fewer appointments for obtaining a diagnosis which reduces expenses and patient inconvenience while increasing the likelihood of treatment if sleep apnea is diagnosed. It also ensures that dentists and physicians are collaborating to provide optimal care for patients and allows for patients’ medical insurance to ap-

propriately cover oral appliance therapy. In no way does it bypass the involvement of a physician in the diagnosis and verification of treatment efficacy and encourages dentists and physicians to work together to refine their practice models. Some of those who have been practicing dental sleep medicine for a while may be saying, “It’s about time the AADSM finally took a position on HSAT,” but we must all remember that it is only in the last two years that we’ve published the standards for practice paper and launched the AADSM Mastery Program. Managing care for patients diagnosed with OSA requires postdoctoral continuing education, training, clinical judgement, collaboration with our medical colleagues, excellent patient care, and an understanding that we are treating a medical disorder. We are now in a position to ensure that dentists have the tools necessary to effectively provide the care outlined in the HSAT position statement. It is one thing to publish a position statement. It is another to ensure the model of care gets implemented and patients realize the benefits of this model. The AADSM will be increasing our education on HSAT, working to get state dental boards currently prohibiting HSAT to change their regulations, and increasing our communications with physicians, the public, and insurers to educate them on this model of care. Our influence on these initiatives is always substantiated by our membership numbers. The biggest step dentists can take to help advance these initiatives is to join the AADSM; it demonstrates that our field is united in reducing the number of undiagnosed and untreated people with sleep apnea.

It is within the scope of practice for a qualified dentist to order or administer HSATs.

David Schwartz, DDS, is President of the American Academy of Dental Sleep Medicine (AADSM) and a Diplomate of the American Board of Dental Sleep Medicine (ABDSM). He has lectured on many aspects of Dental Sleep Medicine and authored and co-authored various articles with the specific intent of continuing to change patients’ lives and the attitudes of professionals worldwide. He has a general restorative dental practice in Chicagoland and has focused on dental sleep medicine for more than 22 years. He is also the director of dental sleep medicine at The Center for Sleep Medicine, a multidisciplinary sleep center.

DentalSleepPractice.com

EXPERT view

In Your Own Words

he American Academy of Dental Sleep Medicine (AADSM) drastically changed their stance on dentists’ involvement with home sleep testing (HST). This landmark position paper boosts dentists’ prestige in the field of sleep medicine and removes obstacles that have impeded patient care. The AADSM’s position has changed, but how will this affect your patients and your practices? We asked a few of your colleagues 3 questions, and here are the answers In Your Own Words. 1. How do you manage sleep testing in your practice? 2. What do you think of the AADSM’s recent position statement? 3. How will this change the way you practice DSM?

Carrie Magnuson, DDS, D.ABDSM

Premier Sleep Associates • Bellevue, WA

1. When a patient presents with no diagnosis, I review the patient’s health history, symptoms, and perform a physical exam. I determine whether HSAT is appropriate versus a PSG or direct oversight from a sleep physician is recommended. If an HSAT is appropriate, I refer to an online sleep testing company with telemedicine capability to prescribe, administer, and interpret the HSAT results with a board-certified sleep physician. The majority of our patients are referred from a sleep physician with diagnostic testing already completed. The local sleep physicians prefer we do not do any follow-up titration evaluation with an HSAT. Instead, we use HRPO testing to evaluate the oxygen levels for advancement recommendations before sending the patient back to the sleep physician for HSAT with their device. 2. I applaud the AADSM Board Members for addressing the nebulous interpretation of dentist’s ability to order a sleep test. With the extraordinary percentage of the population having undiagnosed or untreated SBDs, we can help a sick population get treated in a timely manner. With appropriate training, dentists are certainly qualified to evaluate the symptoms and anatomy of sleep breathing disorders. This will allow the sleep physicians to focus on the more complex patients with sleep

10 DSP | Spring 2021

disorders. Hopefully, the medical insurance companies will acknowledge our qualifications. I look forward to the day when a dentist can prescribe a mandibular advancement device after evaluation and testing. 3. When a patient presents without a diagnosis and is determined appropriate for HST versus a PSG, I give the patient the option of testing from a local sleep physician or an online platform for testing and interpretation. I prefer referring to an online company with telemedicine services as an option and PAP therapy distribution and oversight if needed.

Jeff Rodgers, DMD, D.ABDSM

Sleep Better Georgia • Dunwoody, GA

1. In Georgia, we are not allowed to order diagnostic sleep tests. However, I do use WatchPat HSTs to help with calibration of patients’ devices on a very limited basis. 2. I think it is fantastic and long overdue. I love what is happening at the AADSM under Dr. David Schwartz’s leadership. Access to this care is severely restricted and bringing dentists in at some level could help improve that situation. 3. Unfortunately, not much until the rules are changed in the state of Georgia.

Max Kerr, DDS, D.ABDSM

Sleep Better Austin • Austin, TX

1. 90% of our patients come from physician referrals and have a HST or PSG and diagnosis. In collaboration with the referring physician, we may use HST for titration purposes only and will ultimately refer the patient back for their final study. For the remaining 10%, we either refer them to one of our referring physicians for an HST or we use SleepTest.com 2. This is great and a step in the right direction. I would like HST to be as ubiquitous and routine as blood pressure monitoring and blood panels. It’s crazy to me to think that something as fundamental as sleep rarely gets attention from healthcare professionals. Hopefully this creates

EXPERT view more awareness around sleep dysfunction amongst the patient population. 3. It won’t really alter how we do things. We need our medical colleagues and their governing bodies to be on board with dentists prescribing sleep tests before it will impact our practice. I think we still have a long climb in front of us in that regard.

Erin Elliott, DDS

Sleep Better Northwest • Post Falls, ID 1. We have a hybrid in our practice. Most of the patients are referred to us by physicians, but we also use telemedicine and testing through SleepTest.com. On rare occasions, we dispense our own HST unit and get the diagnosis online. That’s only when absolutely necessary though. 2. I AM IN LOVE!! And so grateful for leadership that ultimately has the patients’ best interest at heart so we can get help to the people that otherwise wouldn’t seek help. The “traditional” way is cumbersome, slow, and patients give up (if they even start to begin with). We HAVE to make it easier for patients to get help. Patients have been overlooked and over-medicated for years. Dentists are in the trenches with those suffering. Sleep physicians are crying out about a shortage in their field. They are saying they have a goal of increasing awareness and diagnosis and then tying the hands of the very people that can help them manage the mild to moderate patients so they can focus on the complex and severe cases. 3. It will open the floodgates of PATIENTS.

Tarun Agarwal, DDS

Raleigh Dental Arts • Raleigh, NC 1. I am a firm believer that dentists can and should play a vital role in assisting patients in the diagnosis of sleep apnea and the education of the adverse health effects related to it. My practice encourages all patients with symptoms or ’telltale’ signs to strongly consider a sleep test to ‘rule out’ the presence of sleep apnea. We offer to refer them to a local sleep physician, work with a telemedicine sleep physician, or the convenience of taking a home sleep test through our office. Our office has 5 HST devices for patient convenience. Each test is scored by a sleep

12 DSP | Spring 2021

tech and officially read by a board-certified sleep physician. We have found that by making it convenient for patients, we help more patients get therapy – CPAP and/or Oral Appliance. 2. While I do feel it should have come much earlier, it’s a welcomed message from the AADSM. Unfortunately, since the AADSM wasn’t proactive, in several states we are now faced with reactively fighting state dental boards to regain the ability to provide HST from dental offices. Worse yet, the lack of guidance has created confusion and fear amongst many dentists to enter the world of dental sleep medicine. It’s my belief that this will take years to overcome. 3. It won’t really change much for me since we’ve been utilizing HST within our practice for years. We’ve developed trusted relationships with sleep physicians and medical professionals within our community. I must admit that there is a ‘sigh of relief’ that encourages me to continue with dental sleep medicine knowing that our most recognized dental sleep medicine organization is standing by us.

John Bouzis, DDS

Restful Sleep Wyoming • Casper, WY

1. I own several testing devices one of which, the NoxT3, provides the availability of the raw data, but I still prefer using outside testing services such as SleepTest. com & DocViaWeb due to their telemedicine services before and after testing, and their ability to provide insurance coverage as we recently lost our community’s sleep physician. 2. If OSA prevalence stats are remotely accurate, it demonstrates a tremendous lack of diagnosis, patient awareness and shows how poorly our present system addresses the disease. Read Jason Tierney’s’ introduction to the winter issue of DSP and I’ll wager most could fill in a name of someone they know – the AADSM position paper is good start to address this! 3. The AADSM position paper will not change a whole lot with how I practice DSM as I am no longer practicing dentistry. Patients usually find me through a medical referral with a request to be tested or as a result of being previously diagnosed and in need of treatment whether it be with PAP or OAT.

COVERstory

Better Sleep Breathing Requires Better Tools by Len Liptak, MBA, Mark T. Murphy, DDS, D.ABDSM, and Keith Batcheller, BS, MA

re humans the fastest runners? No. Cheetahs are twice as fast. Do humans have the best eyesight? Nope. Many birds have double the visual acuity. Are humans the best swimmers? Not even close. So, why are humans exceptional? To paraphrase Steve Jobs, the ability to build and use tools is what makes humans exceptional. Bicycles amplify human locomotion. Computers amplify our ability to calculate. The industrial revolution represents a collection of tools that amplify human labor. Imagining, building, and using tools have exponentially amplified the human existence since the beginning of time. Tens of millions of adults need “tools” to breathe at night. Without them their airways collapse, depriving their bodies of oxygen, and eventually causing dire medical, economic, and societal consequences. Although current tools like legacy OAT devices and CPAPs are deemed better than placebo, significant opportunity for improvement exists. A study of 150 sleep physicians identified a willingness to quadruple referrals for OAT if the devices, the tools, could be improved to be more comfortable, reliable, easy to use, and consistently effective every night. Sleep physicians, DSM providers, and patients want a tool they can truly trust. Imagine the impact on DSM if that happened!

A New Sleep Breathing Tool

ProSomnus EVO™ is a new FDA Cleared OAT medical device that is engineered to ad®

14 DSP | Spring 2021

Figures 1-3: EVO appliance and EVO CAD images

“The moment mankind first picked up a stone or a branch to use as a tool, they altered irrevocably, the balance between themselves and their environment.” – James Burke

dress the challenge for a better sleep breathing tool. Featuring a low profile, anatomical, monolithic, iterative advancement design, EVO is the first OAT device to utilize MG6™ technology. Just as Tesla accelerated the auto industry with the use of advanced materials, Artificial Intelligence, and robotics, ProSomnus is doing this with EVO to create an optimal OAT device. Above all, EVO is designed to earn the trust of DSM providers, sleep physicians, and patients. Let’s take a closer look at this new sleep breathing tool.

Precision Fit and Easy Delivery

One objective for EVO is to make a device that is easy to deliver without compromising precision fit. Liners are a way to achieve easier deliveries. However, liners require significant clinical tradeoffs in the form of suboptimal fit, performance, biocompat-

COVERstory ibility, bulkiness and repair costs – the very types of quality and cost issues that concern sleep physicians and discourage patients. ProSomnus EVO uses patented and proprietary innovations to resolve this compromise. EVO is the first OAT device made from a medical grade Class VI rated material. EVO’s advanced material has better modulus, negating the need for liners. This means the material better conforms to dental anatomy and adapts to variances in dental impressions without conceding precision fit, the orthodontic retention of teeth, nor the other tradeoffs associated with liners. Clinical research indicates that 21% of legacy OATs require problem appointments (Craig et al, 2014). Over 100 EVO cases have been delivered to patients at the time of writing this article. None have required remakes, repairs, or problem appointments.

Robustness and Comfort

Another objective for EVO is to develop a device that is both more robust and more comfortable. There are reasons for DSM providers and OAT manufacturers to chase robustness and comfort. 89% of sleep medicine physicians view poor robustness and 79% view patient discomfort as barriers to more OAT referrals (Granik, 2020). Legacy OAT

Figure 4

“Every appliance has pros and cons. I feel like ProSomnus EVO has finally found the best of all worlds. It is small, strong, precise, but overcomes the stiff feeling and offers a flex that patients find more comfortable. I am a happy camper!” – Erin Elliott, DDS

Mark T. Murphy, DDS, D.ABDSM, is an American Board of Dental Sleep Medicine Diplomate and has practiced in the Rochester area for over 35 years. He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of Funktional Sleep, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and as a Regular Presenter at the Pankey Institute. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion. Len Liptak, MBA, is the CEO of ProSomnus® Sleep Technologies. An award-winning executive with expertise growing and operating innovation-oriented businesses, Len is a founding member of ProSomnus, and co-inventor of the company’s flagship product. Len also serves on the company’s Board of Directors. Len earned an MBA from the University of Minnesota’s Carlson School of Management and a BA from Brown University. A lifelong learner, Len has completed executive education programs at John’s Hopkins, and is a member of the Young President’s Organization (YPO).

Keith Batcheller is the Vice President of Product Marketing for ProSomnus Sleep Technologies. Prior to starting with ProSomnus, Keith was an Orthodontic Business Development Specialist/Consultant for companies in Asia, Europe and North America. Keith has 21 years in the dental/orthodontic space and worked for companies like 3M, Burkhart Dental, Henry Schein Orthodontics and ClearCorrect. Keith was the recipient of the Golden Step Award by 3M for the successful innovation and commercialization of the SmartClip™ Self-Ligating Appliance System and has helped develop and commercialize many of the orthodontic products on the market today. Keith holds a Bachelor of Science degree in Microbiology from the University of Washington and a Master’s degree from Multnomah University in Leadership and Development.

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COVERstory devices have a high rate of failure, despite efforts to add bulk and reinforcements. One study reported that 13% (41/309) of legacy OAT devices required manufacturer repairs or remakes (Craig et al, 2014). EVO uses advanced materials and optimized design to achieve robustness and comfort. EVO material is 10 times more durable than traditional acrylic. EVO features a monolithic splint design, with no secondary components like titration screws or straps. In safety testing for the FDA clearance process, EVO exhibited 52% better anterior/posterior torque strength and 17% better lateral torque strength than the predicate device. As expected, predicate devices exhibited catastrophic failures such as fractures, breakage, permanent stretching or plastic deformations, the EVO material flexed and returned to its pretest shape. Surprisingly, EVO defeated the third-party laboratory destructive testing. EVO features a true anatomical, low profile, comfortable design made possible by MG6 technologies. Overall, EVO is 2.5 times smaller than the average legacy OAT device. EVO also has an optimized, low profile design: 5.0 times lower profile in the lingual areas, 1.5 times lower profile in the facial areas, and 1.3 times lower profile in the titration mechanism areas. The EVO splint component is uniquely designed based on a mirroring of the actual dental anatomy for each patient to create a familiar, comfortable mouth feel. In the IRB study, 100% of patients (21/21) preferred EVO to their CPAPs. 100% (20/20) stated that they would wear EVO more than their CPAPs. 100% (21/21) said EVO would be significantly easier to keep clean than their CPAPs. 93% (26/28) of patients in the IRB study strongly preferred EVO to their legacy OAT

“Being able to slightly flex the EVO device during insertion allows easier placement which is ideal for patients who struggle with stretching their oral commissures. An oral appliance that is flexible and impermeable to external nasties? Are you kidding?” – Kent Smith, DDS, D.ABDSM, D.ASBA

devices. 97% (27/28) said it was easy to close their lips together with EVO. 93% (26/28) strongly agreed that EVO was smaller than their previous OAT device. 97% (29/30) strongly agreed that EVO’s anatomical contours had a more natural, smooth feeling.

Biocompatibility and Stain Resistance

Open up an EVO container. How does it smell? When opening a container for a legacy OAT device it usual smells of residual monomers. Even the newer CAD/CAM hybrid devices still smell like chemicals. Not EVO. EVO material is classified by the United States Pharmacopeia and National Formulary as Class VI. Class VI is the highest grade of material currently available. To achieve Class VI designation, a material must pass a battery of oral, subdermal, and intramuscular toxicity tests. The material for EVO was selected because it satisfied the clinical performance requirements of leading DSM providers while also being Class VI. The main downside of this material is that it is more expensive. Until recently, ProSomnus did not have the buying power to purchase this material at a reasonable price. EVO material is highly resistant to staining. Unlike the lower performance materials used in soft liners, acrylic, and nylon devices, EVO material has better modulus without being as porous. To test stain resistance, an EVO device, a CPAP mask, and a selection of OAT devices were subjected to a 10-day mustard bath test (Fig. 5). A colorimetry score (Delta E) was captured before and after the mustard bath and compared. EVO exhibited virtually no change in color and was on par with the ProSomnus [IA] test device. The CPAP mask was next best, outperforming the traditional acrylic, thermoform, lined CAD/CAM, and nylon material devices.

Precision OAT Evolved

Figure 5

16 DSP | Spring 2021

All manufacturing processes have errors. Think about playing golf or taking an impression. Why is one’s golf swing not perfectly the same every time? Why are impressions not perfect every time? It is because variability error exists in the processes, the materials, the environmental factors, and more. These types of variance errors also exist when transferring a DSM provider’s bite into

PROSOMNUS EVO

™

“ProSomnus EVO reminds me of comfortable cotton socks I put on every morning. They always fit, conforming once in place and you forget about it. Marrying a flexible design without sacrificing the impermeability took some magic. Kudos to ProSomnus!” —Kent Smith, DDS, D.ABDSM, D.ASBA

“I love the ease of delivery for ProSomnus EVO and my patients love the comfort.” —Jason Ehtessabian, DDS, D.ABDSM

“Prescribing ProSomnus EVO has met my needs with first time fit while providing our patients with exceptional durability and comfort. All of this and seeing great results through better efficacy, makes EVO a winning device for our practice.” —Neal Seltzer, DMD, FAGD, D.ABDSM, D.ASBA, D.ACSDD “As with most ProSomnus devices, EVO dropped right in with no adjustments, feels very light and comfortable. Made out of an incredibly strong, but flexible new material. We are happy to include EVO in our device options for DS3 dentists and in our New Concept Sleep offices.” —Gy Yatros, DDS, D.ABDSM “ProSomnus EVO is the gold standard for OAT! As an ENT sleep physician, I must say, this is the kind of solution the medical community has been waiting for.” —Edward T. Sall, MD, DDS, MBA

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COVERstory

Figure 6

the design of an OAT device. Some legacy OAT manufacturing processes have over 50 steps – 50 opportunities for variability! An investigation of bite transfer precision found that the average legacy OAT device has 3.7mm, ranging from 1.2mm to 6.0mm, of global variance between the bite provided and the setup of the device (Hu, 2020). This is significant when considering that the mean protrusive range of the mandible is 8.0mm. ProSomnus devices reproduce the bite accuracy within 0.32mm (Fig. 6). This is largely due to MG6 technologies, including Artificial Intelligence and manufacturing robots, that reduce process steps and variability. ProSomnus also digitally or physically mounts and articulates every case for quality control. To further add value and reduce costs for the DSM practice, EVO comes standard with five arches. This enables 5.0mm of advancement and creates a built-in backup device if a patient loses an arch or a device (Fig. 7). The backup allows the patient to remain in some level of therapy until a replacement can be made.

Overall Impressions

Preliminary efficacy results with EVO show a 83% improvement in AHI, from a baseline of 17.5 to 2.9 (Fig. 8). Some DSM providers will care about certain OAT features and advantages more than others. Some will care about lip competency more than tongue space. Some will care about precision 3D bite transfer more than device bulkiness. Others will have the opposite preferences. Preferences are an important part of ensuring that the OAT device best fits

18 DSP | Spring 2021

Figure 7

“With their sleek design and stain resistance, ProSomnus devices already sell themselves. To now also get material flexibility with the MG6 technology which increases patient comfort and reduces chair-time is just icing on the cake!” – Srujal H. Shah, DDS, D.ABDSM

Figure 8

the needs of the patient and the treatment plan for the DSM provider. What are the overall impressions of EVO? 100% (31/31) would prescribe EVO again. 97% (30/31) would feel very confident prescribing EVO for bruxers. Another 94% (29/31) would feel very confident prescribing EVO for patients with crowns, bridges, or veneers. 97% (30/31) stated that they strongly favor using EVO to treat a wider range of patient types. And most importantly, 100% (31/31) stated that they would recommend EVO to a colleague. ProSomnus’s mission is to improve the lives of millions by designing better tools for DSM providers – tools like the EVO that help people breathe at night. We are wholly committed to providing tools that DSM providers find easy to use, patients love to wear, and physicians trust when prescribing. Join us on this mission.

ProSomnus warmly thanks the dozens of DSM leaders and team members who participated in market research programs, prototype evaluations, and the IRB, alpha and beta tests that were integral to the design and development of EVO.

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BIGGERpicture

Here’s Your Productivity Hack: Go To Sleep by Ryan Holiday

f you read a lot or are someone who gets a lot done, people will assume two things. One, that you’re a speed reader. Two, that you never sleep. In my experience, neither of those assumptions are true. Or at least, they don’t need to be. There’s no trick to reading a lot. But more importantly, no one can skimp on sleep – not for long anyway. The philosopher and writer Arthur Schopenhauer used to say that “sleep is the source of all health and energy.” He said it better still on a separate occasion: “Sleep is the interest we have to pay on the capital which is called in at death. The the interest rate and the more regWhen work higher ularly it is paid, the further the date of reimpedes on sleep, demption is postponed.” of course, that’s not the image we poor planning is likeBut to glorify. We want to see the blearyto blame – not eyed programmer, six Red Bulls deep into startup that will change the world or superior willpower. some the CEO who hops off a redeye and heads straight into the office. We like the story of the writer who stayed up for three days writing a masterwork. We like the musician who works hard, parties hard and sleeps only when they can – usually at the end of a bender. “Sleep when you’re dead,” we say. Like it’s some badge of honor how little time we allot to it.

20 DSP | Spring 2021

I think it’s time to call bullshit. Because the myth is destructive. The benefits minimal. And the claims are dishonest. When work impedes on sleep, poor planning is to blame – not superior willpower. The human body needs its rest, it needs to replenish and burning it out is, as Schopenhauer said, a ridiculously short-sighted strategy. Can some people get by with way less sleep than others? Sure. (Though the research says that for every 100 people who think they need minimal amounts of sleep, only 5-6 are scientifically able to do it without trading performance). But this is not the badge of honor they think. I’m much prouder to say I don’t think I’ve pulled an all-nighter, ever. Even when I was in college, even working three full-time jobs, even when I was on book deadline, I got my seven to eight hours. I didn’t need to – because I handled my shit and had my priorities straight. Not to say I love frittering away time under the covers but I’ll tell you this: Sleep is one of the most important parts of my work routine, period. If some emergency interrupts, I work around it and I bump less important things until I get caught up. I get my 7-8 hours (unless jet lag intervenes). This strategy not only hasn’t affected my output, it’s contributed crucially to my best work. It also means I get by hardly ever using stimulants – basically no coffee, soda, or nicotine needed. Sleep was something people used to brag about. Marc Andreessen – who essentially invented the internet browser – told the Wall Street Journal in 1999 that for him sleeping anything less than six hours a night was suboptimal and that “it makes a big difference in [his] ability to function.” Jeff Bezos has said that he’s “more alert and…think[s] more clearly” if he gets his sleep and that “I just feel so much better all day long if I’ve had eight hours.” Anders Ericcson, of the famous 10,000 hours study, found that master violinists slept 8.5 hours a night on average and took a nap most days. In fact, they slept more than lesser players. But no one seems to want to say that.

BIGGERpicture Yet even with these top performers stressing the importance of sleep, Barclays Bank recently got in trouble for its ridiculous standards for young interns – demanding that they “be the last ones to leave every night… no matter what” and suggesting they bring a pillow to the office. Only after the death of a 21-year-old Merrill Lynch intern (after working 72 hours straight) did Goldman Sachs decide to cap their work days for new employees…at 17 hour days. This is insane, this is stupid, and anyone that would sign themselves up for this isn’t thinking. You can burn yourself out in a few years for someone else at a high salary. OR, you can play the long game. Because one of the most important concepts in economics is the law of diminishing returns. Almost everyone who brags about their long hours and endurance has pushed laughably past it. It’s not performance that keeps them going, it’s just ego and stubbornness. If your job is simply a function of your body existing and being in motion – then sure, the more hours you can put in the better. That is – if you’re a security guard or a doorman or a factory worker or an Uber driver – the longer you can stay at it the more you’ll make (though of course, the risks of accidents increase). But increasingly, fewer of us are. Instead, we work with our minds. The clearer we can think and the better our mental and physical state – the better we will do. Any employer that doesn’t understand that doesn’t have your best interests at heart. They will never be eliciting great work from you. You won’t be your best self. I’ve seen it. I watched as Dov Charney, a brilliant entrepreneur and designer, slowly faltered under the unrelenting workload he subjected himself to. Any employee in any country could call him at any time – and he’d answer. It was a sign of his dedication and his accessibility as a leader, but eventually contributed, I think, to many avoidable mistakes. You know that tall tale about John Henry, the man who challenged the machine and won? People forget, that at the end of it he died of exhaustion. There’s a great piece by Shane Parrish from Farnam Street in which after looking at all the research, he found that the single best productivity secret was this: Waking up early. Because there were fewer distractions and you had quiet time yourself – you’re in control, not the busy world. He doesn’t say deprive yourself of

sleep to accomplish it, of course. But he’s urging you to examine the effects that something as simple as schedule can have on your output – both in terms of quantity but also quality. The same goes for the amount of sleep and the priority you place on its role in your life. If sleep is a luxury, it will be the first to go when you get busy. If sleep is what happens only when everything is done, work and others will constantly be impugning on your personal space. But with boundaries and an understanding of the benefits of sleep – it becomes less optional and more about optimization. We only have so much energy for our Anders Ericcson, work, for our relationships, for ourselves. A smart person understands this and guards it of the famous carefully. Meanwhile, idiots focus on mar- 10,000 hours study, ginal productivity hacks and gains while they leak out energy each passing day. The found that master greats – they protect their sleep because violinists slept 8.5 it’s where the best work comes from. They say no to things. They turn in when they hit hours a night on their limits. They don’t let the creep of sleep average and took a deprivation undermine their judgment. A young Paul Johnson, who would nap most days. eventually become a great writer and biographer, once asked Winston Churchill, a man notorious for his insistence on eight hours a night plus a nap each day, even during the war: “Sir, to what do you attribute your success in life?” Immediately, Churchill replied, “Conservation of energy. Never stand up when you can sit down, and never sit down when you can lie down.” To that I would add: and when you can’t keep your eyes open, go to sleep. When you hit your limits, listen. The body is telling you something. Rest. Then start again the next day fresh. Play the long game.

Ryan Holiday is one of the world’s foremost thinkers and writers on ancient philosophy and its place in everyday life. He is a sought-after speaker, strategist, and the author of many bestselling books including The Obstacle Is the Way; Ego Is the Enemy; The Daily Stoic; and the #1 New York Times bestseller Stillness Is the Key. His books have been translated into over 30 languages and read by over two million people worldwide. He lives outside Austin, Texas, with his family.

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CONTINUING education

Oral Appliance Therapy; The Definition of Effectiveness by John Viviano, DDS, D.ABDSM

debate rages. Neither side is willing to listen to the other or objectively evaluate the data. The polarization intensifies and each side is becoming more emboldened and increasingly impassioned in their beliefs. It’s ubiquitous in the U.S., but sadly, also common in Canada and many other developed countries.

Of course, I’m referring to the debate regarding the effectiveness of Oral Appliance Therapy (OAT) compared to Positive Airway Pressure (PAP). Efficacy refers to a therapy’s performance under “ideal” and controlled circumstances. Effectiveness refers to an evaluation of its performance under ‘real-world’ conditions.1 Research data tells us what efficacy is. As clinicians, effectiveness is what we strive to optimize for every patient we treat; first by meeting the published minimum efficacy outcomes and then by attempting to further ameliorate treatment outcomes via modifications for specific patients based on their particular presentations. A recent systematic review and meta-analysis regarding the effectiveness of PAP and OAT in the treatment of Obstructive Sleep Apnea (OSA) clearly demonstrated that PAP is far superior to OAT in the reduction of Apnea Hypopnea Index (AHI).2 AHI is the metric currently used to establish sleep

Educational Aims

This article aims to discuss the effectiveness of Oral Appliance Therapy (OAT) and provide an evidence-based comparative assessment to the effectiveness of Positive Airway Pressure (PAP). Various strategies useful for improving OAT effectiveness when they fall short of expectations will also be discussed.

Expected Outcomes

Dental Sleep Practice subscribers can answer the CE questions online at dentalsleeppractice.com/ce-articles to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will: 1. Identify how OAT compares to PAP therapy for a particular patient 2. Realize factors that determine how effective a therapy is 3. View patient care with OAT from a pragmatic evidence-based perspective 4. Determine which adjunctive therapies are indicated for a particular patient

22 DSP | Spring 2021

apnea severity, and physicians typically refer to PAP criteria of normalizing the AHI to below 5 to establish a successful outcome. This is problematic because while more than 1/3 of OAT cases will meet this criterion, another 1/3 will experience a clinically important reduction of >50% but remain above 5 AHI, and the final ~1/3 will not achieve this >50% reduction.3 These findings further bolster the position that PAP is Gold Standard Therapy for Sleep Apnea. In a recent paper describing effective Oral Appliance Therapy (OAT), the American Academy of Dental Sleep Medicine (AADSM) states,4 “A properly fitted oral appliance worn nightly will decrease the frequency and/or duration of apneas, hypopneas, respiratory effort related arousals (RERAs) and/or snoring events. Oral appliances have been demonstrated to improve nocturnal oxygenation as well as the adverse health and social consequences of OSA and snoring.” Note that the expectation is to “decrease” and “improve.” There is no mention of normalizing AHI. However, there is a very large elephant in the room wearing a gigantic sign that says, “I can’t wear PAP!” This elephant is routinely ignored by physicians with very sound reason; physicians are accustomed to patients not complying with prescriptions. For example, approximately 50% of hypertension medications are taken as prescribed,5 as few as 12% of asthma sufferers take their asthma meds as prescribed,6 and the National Association of Chain Drug Stores documents that only 25-30% of patients actually fill and take medications as prescribed.7 In contrast, the 2015 Frost and Sullivan report8 documents that 60% of Americans diagnosed with Sleep Apnea remain compliant with PAP; suggesting that sleep medicine is faring very well regarding PAP compliance. From a physician’s perspective, medicine is managing approximately 2/3 of the pa-

CONTINUING education tients; 1/3 optimally with all-night wear and 1/3 sub-optimally with partial night wear. Viewed from a different vantage point, medicine is mismanaging 2/3 of the patients; 1/3 are sub-optimally managed, wearing PAP only part of the night, and 1/3 are unable to tolerate PAP therapy at all (Figure 1).

PAP and OAT Effectiveness – Adherence is Key

A recent comprehensive, systematic literature review involving 82 papers, spanning 1994-2015 found that, “CPAP adherence remains persistently low over twenty years’ worth of reported data”9 It is interesting that the most current PAP guidelines published in 201910 make no mention of these findings and simply continue to refer to PAP as gold standard therapy. The guidance provided for patients having difficulty with PAP remains unchanged in the latest PAP guidelines; try a different mask interface, reduce the pressure, add humidification, or try AutoPAP or BiPAP. This does not foster much hope for improvement in PAP adherence. Alternative therapies are referenced, and OAT is briefly mentioned, bundled into a paragraph on alternative therapies. There is no mention that OAT is currently indicated as a “Standard of Care” for any severity of OSA if the patient cannot tolerate PAP or prefers an oral appliance to PAP. Without any guidance for the sleep physicians, how can one expect them to know how, when, and for whom OAT is appropriate? In contrast, the current OAT guidelines explicitly state that PAP is the “Gold Standard” and first line therapy for OSA, providing clear guidance to dentists about the use of PAP. 11 The aforementioned meta-analysis demonstrating superiority of PAP for normalizing AHI also documented the clear superiority of OAT regarding treatment adherence.2 Patient preference heavily favoring OAT was one rationale for the 2015 OAT guidelines indicating OAT be a “Standard of Care” for all severities of OSA.11 Other studies also document higher patient preference and adherence for OAT. A study comparing a titrated oral appliance with PAP found that side effects existed with both therapies, that they were of similar intensity and frequency, and that OAT was preferred by >70% of the patients.12 Another recent cross-over study comparing OAT and PAP (both utilized ad-

Figure 1: Provided by the author

herence tracking) found that patients preferred OAT to PAP in all variables investigated, with the average rating across all variables favoring OAT (80.3%) vs. PAP (19.7%).13 A number of other investigators have similarly concluded that patients prefer OAT to PAP.14,15,16,17 Over the past decade a number of publications have documented the similarity of PAP and OAT outcomes. Objectively measured health outcomes such as psychomotor speed, driving simulator performance, cardiovascular system outcomes and mortality have been demonstrated to be similar for both PAP and OAT.18 Functional outcomes such as snoring, sleepiness, neurocognitive function, quality of life, and mood have also been found to be similar with both therapies. PAP has been shown to be slightly better at snoring reduction while OAT scores slightly higher in the improved Quality-of-Life category.13 It is important to note that blood pressure outcomes18 and measurements of cardiovascular mortality19 have both been demonstrated to be similar with PAP and OAT. How does one reconcile that PAP is superior to OAT in normalizing AHI, yet health outcomes are similar? Let’s circle back to the elephant in the room that too many choose to ignore; poor patient adherence associated with PAP. Let’s start by refining our understanding of PAP adherence, which when using

Dr. Viviano obtained his credentials from the University of Toronto in 1983. His clinic is limited to managing sleep-disordered breathing and sleep-related bruxism. He is a Credentialed Diplomate of the American Board of Dental Sleep Medicine and has lectured internationally, conducted original research, and authored original articles on the management of sleep-disordered breathing. His clinic is the first Canadian facility accredited by the American Academy of Dental Sleep Medicine and he is Clinical Director of the Sleep Disorders Dentistry Research and Learning Centre. Dr. Viviano also hosts the SleepDisordersDentistry LinkedIn Discussion Group and conducts dental sleep medicine CE programs for various levels of experience, including a 4-day mini residency. Dr. Viviano’s Class and Cloud Based CE programs can be found on SDDacademy.com, and he can be reached at (905) 212-7732 or via the website sleepdisordersdentistry.com.

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CONTINUING education a commonly cited benchmark of 4 hours use/night, 5 nights/week, is approximately 50% at 6 months and 17% at 5 years.20,21,22,23 A recent publication documented that the likely PAP adherence profile for a particular patient is strongly associated with their initial experience with it. This study, which evaluated predictors of PAP adherence found, “the strongest predictors of adherence at 24 months were early adherence measures. Adherence in the first month was the most predictive of adherence at 24 months.”20 Patients that do adhere to PAP, actually wear it varying number of hours nightly – 4 hours is deemed necessary to demonstrate adherence. PAP adherent patients often do not demonstrate superior outcomes to OAT patients, even when the OAT does not fully normalize AHI. This may be explained by the “Dose Dependent Effect.” The literature documents that PAP health benefits are related to usage; for instance, 6 hours nightly for objective sleepiness to be resolved, greater than 5.6 hours nightly for objective hypertension to be resolved and more than 6 hours nightly is associated with the greatest mortality risk reduction.23 Navarro-Soriano et al. recently documented that both cardiovascular events and development of hypertension had a dose dependent relationship with hours of PAP use;24 patients using PAP < 4 hours per night were 5.1 times more likely to develop severe hypertension. A dose dependent effect for PAP use on sleepiness has also been shown.25 When McEvoy et al.26 evaluated the incidence of cardiovascular events with PAP wear compared to controls, they found no difference. On the other hand, Anandam et al.19 demonstrated a reduction in events over controls; patients wore PAP an average of 3.3 hours in the McEvoy study vs. 5.8 hours in the Anandam study, once again, suggestive of a dose dependent effect. In contrast, OAT adherence is very high, documented to be approximately 90% measured subjectively,27 and 85.9% measured objectively.28 When measured objectively, nightly use has been shown to be approximately 7.5 hours.28 A long-term follow-up study documenting use after

5.7 +/- 3.5 years found that, among adherent patients, 93.7% used the oral appliance more than 4 nights per week, 100% wore it more than half of each night, and 95% were satisfied with the treatment.29 In 2013, Vanderveken et al30 documented the safe use of an intra-oral OAT objective adherence monitor. This enabled for the first time, the calculation of OAT Mean Disease Alleviation (MDA), defined as a combined function of efficacy and adherence, and representing a measure of the overall therapeutic effectiveness. Over the following 2 years, this concept evolved further23,31 resulting in the development of the SARAH Index, (Sleep Adjusted Residual AHI), defined as [(AHI treated X Hours treated) + (AHI untreated X Hours untreated)] divided by Total Sleep Time (See Figure 2). When either the MDA or Sarah Index are calculated, OAT is found to be similar to PAP, with overall effectiveness hovering around 50% for both.23,30 This is thought to be the reason for the similar health benefits OAT and PAP deliver. The common medical consensus has been that high PAP efficacy would transfer into “real-life” circumstances, and that PAP effectiveness would equal its efficacy. PAP has fallen short of this mark and demonstrates an effectiveness similar to OAT in “real-life” circumstances (See Figure 3).

The Real-World Effectiveness Equation

Figure 2: SARAH Index. Adapted from Sutherland et al.23

Figure 3: Comparison of treatment effectiveness profile of CPAP and oral appliances. Adapted from Sutherland et al.23

24 DSP | Spring 2021

SomnoMed, a leading OAT manufacturer, has taken these concepts and created a software algorithm that can be used to determine the effectiveness of PAP and OAT for a particular patient. It takes into consideration baseline AHI, post-therapeutic PAP and OAT AHI, and the length of use for both therapies. The results are quite surprising, even when one is already aware of the MDA concept. Case I (See Figure 4) involves a patient with a baseline AHI of 99. Post-therapeutic PAP AHI was 3.9, but OAT fell short with an AHI of 27.9. In most offices, this oral appliance effort would be dismissed as ineffective and the patient would be encouraged to continue with PAP. This particular patient could tolerate PAP for 5.5 hours per night and would likely be told they are adherent, as the minimum expectation is 4 hours, 5 nights/ week. Any attempts on the patient’s part of expressing the opinion that their OA provides them a similar benefit to their PAP would be

CONTINUING education dismissed due to the OA’s inability to reduce the AHI below 5. The patient would be told that their oral appliance is ineffective. The SomnoMed Effectiveness Equation (Somnomed, Plano, TX) demonstrates the total number of events on PAP was 268 and on OAT was 258. So, the number of arousals from sleep, and the number of desaturations occurring each night were similar and in fact, marginally less with OAT. Once again, this helps to explain why health outcomes of both therapies are comparable and why patients often claim that they feel similarly with both therapies even though they have residual apnea with the oral appliance. Case II (see Figure 5) involves a patient with baseline AHI of 27.6. Post-therapeutic PAP AHI was 4.5, but OAT fell short with an AHI of 12.5. Once again, in most offices, this appliance effort would be dismissed as ineffective and the patient would be encouraged to continue with PAP. In this particular case, the patient could tolerate PAP for 5 hours per night, surpassing minimum expectations and thus considered adherent. Once again, any attempts on the patient’s part of expressing the opinion that their OA provides them a similar benefit to their PAP would be dismissed. What does the SomnoMed Effectiveness Equation tell us? The total number of events on PAP was 105 and on OAT was 107. The number of arousals from sleep, and the number of desaturations occurring each night were similar with both therapies. Nevertheless, this patient would be encouraged to stay with PAP and discouraged from wearing their oral appliance. We must keep in mind that the 1/3 of patients that happily wear PAP throughout their sleep period are being optimally managed. It is the next 1/3 that wear PAP only part of the night and are sub-optimally managed and the last 1/3 that cannot tolerate wearing PAP at all that can benefit greatly from OAT. Patient preference is clearly related to adherence, and adherence is clearly related to outcomes. However, there are also potential confounders to the MDA and SARAH Index approach. These include what we don’t know regarding continued therapeutic effectiveness once PAP and or OAT are removed each night, whether routinely not wearing PAP later in sleep period holds implications due to being exposed to more events during

Figure 4: CPAP vs SomnoDent effectiveness determined using the SomnoMed Effectiveness Equation

Figure 5: CPAP vs SomnoDent effectiveness comparison for Case II

REM sleep and the lack of any accounting for what position and in which sleep stage the events are occurring. The Achilles heel of PAP therapy is adherence, and the current PAP guidelines provide guidance regarding the management of patients that have difficulties with PAP adherence.10 The Achilles heel for OAT is residual AHI. Fortunately, there is an abundance of evidence-based guidance available to offer these patients as well (See Figure 6).

Patient preference is clearly related to adherence, and adherence is clearly related to outcomes.

When OAT Outcomes Fall Short

The MDA concept is not a pass to accept a sub-optimal outcome. When OAT falls short of the mark in normalizing AHI, then DentalSleepPractice.com

CONTINUING education

Figure 6: Strategies to deal with PAP adherence difficulties and OAT residual AHI

the first thing to do is ensure the appliance is optimally calibrated. For some patients this may mean further advancement, and it is important to remember that the patient’s ability to tolerate a certain level of advancement is an adaptive capacity that generally increases with time. So, what is uncomfortable today, will not necessarily be uncomfortable tomorrow. Next, consider altering vertical if the appliance is adaptable. To avoid making changes to vertical after the fact, consider building your original appliances using a vertical based on phenotype developed by Levendowski that was created when he developed the ApneaGuard.32 Generally, this involves using more Vertical Opening Dimension (VOD) for heavier males and less VOD for petite females. Finally, if the appliance does not restrain the lower component from dropping open in supine sleep, apply elastics and determine if preventing the mandible from dropping during supine sleep helps to normalize any residual supine related apnea. Milano et al. demonstrated an improvement in outcomes with elastic use for patients with supine related AHI.33 See Figure 7.

Adjunctive Therapies to Optimize Outcomes

Figure 7: ProSomnus appliance (top) and Panthera D-SAD with and without elastics (bottom)

Figure 8: Combo therapy provides options

26 DSP | Spring 2021

For those patients continuing to experience inadequate outcomes, even after the oral appliance is optimally calibrated, there are a number of adjunctive therapies that can further improve outcomes. Often referred to as combination or hybrid therapy, combining PAP and OAT has been shown to increase PAP compliance34 and improve overall outcomes.35 When a patient has access to both therapies, it provides them options; they can wear both all night long, they can start with both and take their PAP off when they are done with it and continue with their OAT, they can wear their PAP as long as possible, and when they remove it they can switch to their oral appliance that is kept on their night stand, and finally, they can start with their oral appliance and move to their PAP part way through the night. The patient can experiment and find what works for them. See Figure 8. For those patients carrying excess weight, weight reduction can help the cause dramatically. A 10% loss in weight has been associated with a 26% decrease in AHI.36 It is also

CONTINUING education important to note that aerobic exercise results in a, “reduction in disease severity and in daytime sleepiness, as well as an increase in sleep efficiency and in peak oxygen consumption, regardless of weight loss.”37 For patients experiencing residual supine AHI, all that may be required is to add positional therapy to the regimen; adjunctive use of positional therapy has been demonstrated to improve both tongue-retaining device38 and OAT39 outcomes. Positional therapy combined with OAT have actually been demonstrated to be as effective as PAP for positional OSA.40 A number of positional aides are currently available to help facilitate positional therapy; for example, vibratory devices that vibrate when the patient is in supine position, encouraging a change to non-supine position and strap-on devices that make supine sleep uncomfortable thus encouraging non-supine sleep. Further on position, wedges that elevate the head position by as little as 15 cm have been demonstrated to reduce AHI in both supine and non-supine position.41 See Figure 9. Nasal patency is another area to investigate. Higher nasal resistance has been demonstrated to be predictive for OAT outcomes.42 Once again, a number of over-thecounter aides are available to improve nasal patency making it simple and inexpensive to evaluate the potential for benefit. Currently, palatal surgery is rarely considered primary therapy for OSA, however, combining palatal surgery with OAT has resulted in favorable outcomes.43 A systematic review and meta-analysis of the Myofunctional therapy literature demonstrated that it reduces AHI by approximately 50% and also decreases oxygen desaturations, snoring and sleepiness in adults. An even larger AHI decrease of 62% has been demonstrated for children.44 Used adjunctively, Myofunctional therapy could help resolve residual AHI. Further along these lines, a novel technology has been introduced recently that utilizes neuromuscular stimulation of the genioglossus muscle during day hours to improved muscle physiology, demonstrated to be effective for mild OSA45 it is currently being investigated for its clinical utility for moderate to severe OSA. And finally, some additional adjunctive efforts include improving sleep hygiene,46 and a variety of lifestyle modifications such as re-

Figure 9: Positional aides that encourage non-supine sleep and elevate the head of the bed.

ducing smoking47 and alcohol consumption48 and reducing use of central nervous system depressants.49 Once all of the above have been exhausted, you can confidently accept that both your oral appliance and your oral appliance treatment effort have been optimized. In this case, should the result be unacceptable, there are a number of surgical options available, such as Maxillary-Mandibular Advancement surgery50 and implanted tongue neuromuscular stimulation devices.51 The continued use of AHI as a metric to evaluate OSA severity is currently being challenged,52,53,54,55 with the literature suggesting a “reconsideration of the role of AHI as the prime diagnostic metric.”52 It is interesting that shortly before coining the term “Apnea Index”,56 the authors preferred to report the total number, or duration, of nocturnal apneas,57,58 rather than the number per hour of sleep. Based on what the literature currently documents regarding adherence, health outcomes, and MDA, had this alternative definition been established in 1978, we would have had a different perspective on the therapeutic effectiveness of OAT all these years. In summary, OAT effectiveness has been demonstrated to be similar to PAP when viewed through the lens of MDA; a conclusion, supported by an abundance of literature evidence. Thus, rather than focusing on the AHI exclusively, we have discussed the importance of also considering adherence levels when comparing PAP and OAT outcomes. All stakeholders – physicians, dentists, technologists, and auxiliaries should be familiar with these concepts and they should be discussed openly when evaluating and comparing outcomes achieved by PAP and OAT. Our patients can be best served when we communicate accurately and consistently regarding their care. Finally, OAT providers should be careful to ensure that every effort has been made to optimize treatment outcomes by first optimizing the actual oral appliance, and then utilizing patient appropriate adjunctive therapies in an effort to further improve outcomes. Patients can be best helped by physicians and dentists working collaboratively to provide the best solution for that particular patient.

1. 2. 3.

Revicki DA, Frank L. Pharmacoeconomic evaluation in the real world. Effectiveness versus efficacy studies. Pharmacoeconomics. 1999;15:423–434. Schwartz, M. et al. Effects of CPAP and mandibular advancement device treatment in OSA patients: a systematic review and meta-analysis. Sleep Breath 2018: 22, 555–568 Sutherland K, Vanderveken OM, Tsuda H, et al. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10:215–27.

DentalSleepPractice.com

CONTINUING education 4.

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

14.

15.

16.

17. 18. 19. 20.

21.

22. 23. 24.

25. 26. 27. 28. 29.

30. 31. 32.

33. 34. 35. 36.

Kenneth Mogell, DMD, D. ABDSM (Chair)1; Norman Blumenstock, DDS, D. ABDSM2; Erika Mason, DDS, D. ABDSM, D. ACSDD3; Rosemarie Rohatgi, DMD, D. ABDSM4; Srujal Shah, DDS, D. ABDSM5; David Schwartz, DDS, D. ABDSM (Board Liaison)6 Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: An Update for 2019 JDSM Vol. 6, No.3 2019 Bernard Vrijens, chief scientist and adjunct professor of biostatistics,1,2 Ga¨bor Vincze, principal health economist ,3 Paulus Kristanto, senior biostatistician ,1 John Urquhart, professor of biopharmaceutical sciences ,4 Michel Burnier, professor of nephrology5 Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories BMJ doi:10.1136/bmj.39553.670231.25 on 14 May 2008 Lemiere et al. Adult Asthma Consensus Guidelines update 2003 Can Respir J. 2004;11(Suppl A):9A–18A National Association of Chain Drug Stores, Pharmacies: Improving Health, Reducing Costs, July 2010 Frost & Sullivan. “Vital Signs, The Price of a Good Night’s Sleep: Insights into the US Oral Appliance Market” Commissioned by the AASM. January 2015 Rotenberg et al. Trends in CPAP adherence over twenty years of data collection: a flattened curve Journal of Otolaryngology - Head and Neck Surgery (2016) 45(43) Patil SP, et al. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335–343 Ramar K, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827 Gagnadoux et al. Titrated mandibular advancement versus positive airway pressure for sleep apnoea Eur Respir J 2009; 34: 914–920 Yamamoto et al., Crossover comparison between CPAP and mandibular advancement device with adherence monitor about the effects on endothelial function, blood pressure and symptoms in patients with obstructive sleep apnea Heart Vessels 2019: 34, 1692–1702 Kathleen A Ferguson, Takashi Ono, Alan A Lowe, Sulaiman Al-Majed, Leslie L Love, John A Fleetham A short term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea Thorax 1997,52:362–368 Randerath WJ., Heise M., Hinz R., Ruehle KH., An Individually Adjustable Oral Appliance vs Continuous Positive Airway Pressure in Mild-to-Moderate Obstructive Sleep Apnea Syndrome. CHEST Vol 122, Issue 2, P569575, August 2002 Tan YK., L’Estrange PR., Luo YM., Smith C., Grant HR., Simonds AK., Spiro SG., and Battagel JM., Mandibular advancement splints and continuous positive airway pressure in patients with Obstructive sleep apnoea: a randomized cross-over trial. European Journal of Orthodontics 24(2002) 239-249 Philips, Gozal & Malhotra, What is the Future of Sleep Medicine in the United States AJRCCM 2015: 192(8), 915-917 Bratton et al., CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With OSA: A Systematic Review and Meta-analysis. JAMA. 2015;314(21):2280-2293 Anandam et al., Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: An observational study. Respirology, 2013: 18(8),pp1184-1190 Emer Van Ryswyk1,*, , Craig S. Anderson2,3, Nicholas A. Antic1, Ferran Barbe4,5, Lia Bittencourt6,7, Ruth Freed2, Emma Heeley2, Zhihong Liu8, Kelly A. Loffler1, Geraldo Lorenzi-Filho9, Yuanming Luo10, Maria J. Masdeu Margalef11, R. Doug McEvoy1,12, Olga Mediano13, Sutapa Mukherjee1,12, Qiong Ou14, Richard Woodman15, Xilong Zhang16 and Ching Li Chai-Coetzer1,12,*; on behalf of the SAVE Investigators and Coordinators Predictors of long-term adherence to continuous positive airway pressure in patients with obstructive sleep apnea and cardiovascular disease SLEEPJ, 2019, Vol. 42, No. 10, 1-9 Bartlett D; Wong K; Richards D; Moy E; Espie CA; Cistulli PA; Grunstein R. Increasing adherence to obstructive sleep apnea treatment with a group social cognitive therapy treatment intervention: a randomized trial. SLEEP 2013;36(11):1647-1654 Catcheside PG., Predictors of continuous positive airway pressure adherence. F1000 Medicine Reports. September 2010, 2:70 Sutherland K, Phillips CL, Cistulli PA. Efficacy vs. effectiveness in the treatment of OSA: CPAP and oral appliances. Journal of Dental Sleep Medicine 2015;2(4):175–181 Navarro-Soriano et al., Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study Arch Bronconeumol. 2020 https://doi. org/10.1016/j.arbres.2019.12.006 Weaver TE; Maislin G; Dinges DF et al. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. SLEEP 2007;30(6):711-719 McEvoy RD. et al., CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea. n engl j med 375;10 September 8, 2016 Yoshida K. Effects of a Mandibular Advancement Device for the Treatment of Sleep Apnea Syndrome and Snoring on Respiratory Function and Sleep Quality. J Craniomandibular Practice. April 2000, Vol.18. No.2 Ngiam, Poster Presented ASA Meeting 2015 Fernanda Ribeiro de Almeida 1, Alan A Lowe, Satoru Tsuiki, Ryo Otsuka, Mary Wong, Sandra Fastlicht, Frank Ryan Long-term compliance and side effects of oral appliances used for the treatment of snoring and obstructive sleep apnea syndrome J Clin Sleep Med 2005 Apr 15;1(2):143-52. Vanderveken OM. et al. Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax 2013; 68:91-6 Ravesloot MJ, de Vries N, Stuck BA. Treatment adherence should be taken into account when reporting treatment outcomes in obstructive sleep apnea. Laryngoscope 2014;124:344–5. Levendowski D, Popovic D, Morgan T, Melzer V, Westbrook PR. Assessing Changes in the AHI Resulting from Increased Vertical Dimension of Occlusion (VDO) of Mandibular Repositioning Devices. Sleep Breath 2009; 13:308. Milano F., et al. Influence of Vertical Mouth Opening on Oral Appliance Treatment Outcome in Positional Obstructive Sleep Apnea. JDSM 2018;5(1):17-23 El-Solh, Ali A. et al. Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study. Sleep Breath (2011) 15:203-208 Liu et al. Combining MAD and CPAP as an effective strategy for treating patients with severe sleep apnea intolerant to high-pressure PAP and unresponsive to MAD PloS One 13(4) 2018 PE Peppard et al, Longitudinal Study of Moderate Weight Change and Sleep-Disordered Breathing. JAMA December 20, 2000. Vol 284 No 23

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37. Maciel Dias de Andrade and Pedrosa, The role of physical exercise in obstructive sleep apnea. J Bras Pneumol. 2016 Nov-Dec; 42(6): 457–464 38. Cartwright RD et al., A Comparative Study of Treatments for Positional Sleep Apnea. Sleep 1991: 14:546–552 39. Dieltjens M., et al. A promising concept of combination therapy for positional obstructive sleep apnea. Sleep Breath (2015) 19:637–644 40. Takaesu Y, Tsuiki S, Kobayashi M, Komada Y, Nakayama H, Inoue Y. Mandibular advancement device as a comparable treatment to nasal continuous positive airway pressure for positional obstructive sleep apnea. J Clin Sleep Med 2016;12(8):1113–1119. 41. Souza et al., The influence of head-of-bed elevation in patients with obstructive sleep apnea. Sleep Breath. June 24, 2017; DOI 10.1007/s11325-017-1524-3 42. Park CY., et al., Clinical Effect of Surgical Correction for Nasal Pathology on the Treatment of Obstructive Sleep Apnea Syndrome. PLoS One. 2014; 9(6): e98765. 43. RP Millman et al. The efficacy of oral appliances in the treatment of persistent sleep apnea after uvulopalatopharyngoplasty. Chest. 1998 Apr;113(4):992-6 44. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. SLEEP 2015;38(5):669–675. 45. Wessollek et al., Somnologie. September 2018; 22(Suppl 2) 46. Jung SY., et al., Sleep hygiene-related conditions in patients with mild to moderate obstructive sleep apnea. Auris Nasus Larynx 2019 Feb;46(1):95-100 47. Krishnan V., et al., Where There Is Smoke…There Is Apnea: Exploring the Relationship Between Smoking and Sleep Apnea. Chest 2014 Dec; 146(6):1673-1680 48. Simou E., et al., Alcohol and the risk of sleep apnoea: a systematic review and meta-analysis. Sleep Med. 42: 38-46 49. Guilleminault C., Benzodiazepines, breathing, and sleep. Am J Med. 1990 Mar 2;88(3A):25S-28S 50. Soroush Zaghi, MD; Jon-Erik C. Holty, MD, MS; Victor Certal, MD; Jose Abdullatif, MD; Christian Guilleminault, DM, MD, DBiol; Nelson B. Powell, MD, DDS; RobertW. Riley, MD,MS, DDS; Macario Camacho,MD Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea A Meta-analysis JAMA Otolaryngol Head Neck Surg. 2016;142(1):58-66. doi:10.1001/ jamaoto.2015.2678 Published online November 25, 2015. 51. Patrick J. Strollo, Jr., M.D., Ryan J. Soose, M.D., Joachim T. Maurer, M.D., Nico de Vries, M.D., Jason Cornelius, M.D., Oleg Froymovich, M.D., Ronald D. Hanson, M.D., Tapan A. Padhya, M.D., David L. Steward, M.D., M. Boyd Gillespie, M.D., B. Tucker Woodson, M.D., Paul H. Van de Heyning, M.D., Ph.D., Mark G. Goetting, M.D., Olivier M. Vanderveken, M.D., Ph.D., Neil Feldman, M.D., Lennart Knaack, M.D., and Kingman P. Strohl, M.D., for the STAR Trial Group* Upper-Airway Stimulation for Obstructive Sleep Apnea N Engl J Med 2014;370:139-49. DOI: 10.1056/NEJMoa1308659 52. Pevernagie DA., Gnidovec-Strazisar B., Grote L, Heinzer R., McNicholas WT., Penzel T., Randerath W., Schiza S., Verbraecken J., Arnardottir ES., On the Rise and Fall of the Apnea-Hypopnea Index: A Historical Review and Critical Appraisal. Journal of Sleep Research. D01: 10.1111/jsr.13066 53. David M. Rapoport. Point: Is the Apnea-Hypopnea Index the Best Way to Quantify the Severity of Sleep-Disordered Breathing? Yes Chest 149 #1 January 2016 54. Naresh M. Punjabi Counterpoint: Is the Apnea-Hypopnea Index the Best Way to Quantify the Severity of Sleep-Disordered Breathing? No Chest 149 #1 January 2016 55. Eyal Shahar. Apnea-hypopnea index: time to wake up. Nature and Science of Sleep. 2014:6 51-56 56. Guilleminault C, van den Hoed J, Mitler MM. Clinical overview of the sleep apnea syndromes. In: Guilleminault C, Dement WC, editors. Sleep Apnea Syndromes. New York, NY, USA: Alan R Liss, Inc.; 1978. 57. Guilleminault C, Eldridge FL, Tilkian A, Simmons FB, Dement WC. Sleep apnea syndrome due to upper airway obstruction: a review of 25 cases. Arch Intern Med. 1977;137:296–300. 58. Guilleminault C, Tilkian A, Lehrman K, Forno L, Dement WC. Sleep apnoea syndrome: states of sleep and autonomic dysfunction. J Neurol Neurosurg Psychiatry. 1977;40:718–725.

CONTINUING education

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Oral Appliance Therapy; The Definition of Effectiveness by John Viviano, DDS, D.ABDSM

1. Efficacy refers to __________ a. a therapy’s performance under “ideal” and controlled circumstances. b. an evaluation of its performance under ‘real-world’ conditions c. neither a or b d. both a and b 2. The National Association of Chain Drug Stores documents that ____% of patients actually fill and take medications as prescribed. a. 10 b. 25-30 c. 50-65 d. 82 3. Numerous studies have shown that the majority of patients prefer OAT to PAP therapy. a. True b. False 4. Mean Disease Alleviation (MDA) is defined as _________ a. The total AHI after wearing OAT for 90 days b. A combined function of efficacy and adherence that represents a measure of overall therapeutic effectiveness c. The algorithm used in sleep labs to titrate PAP d. None of the above 5. Patients using OAT and suffering from supine related AHI may benefit from _________ a. Elastic straps b. Posterior disclusion c. Increased VOD

d. All of the above 6. The SARAH Index a. [(AHI treated X Hours treated) - (AHI untreated X Hours untreated)] divided by Total Sleep Time b. (Supine AHI + RERAs) divided by Total Sleep Time c. [(AHI treated X Hours treated) + (AHI untreated X Hours untreated)] divided by Total Sleep Time 7. A 10% loss in weight has been associated with _______ a. 17% decrease in AHI b. The power of invisibility c. 26% decrease in AHI d. Decreased leptin levels of 12 – 23% 8. Patients using PAP < 4 hours per night were 2 times more likely to develop severe hypertension. a. True b. False 9. Research has shown blood pressure outcomes and measurements of cardiovascular mortality with PAP to be ________ compared to OAT. a. Better b. Worse c. About the same 10. A recent study found that PAP adherence _______________ was the most predictive of adherence at 24 months. a. Based on mask material b. In the first month c. In the first 90 days d. None of the above DentalSleepPractice.com

CLINICALfocus

It is Time to Reëvaluate AHI’s Role in Decision Making by Barry Glassman, DMD, and Don Malizia, DDS

entistry has an affinity for “cookbook” decision making regarding diagnosis and treatment. Finding a radiolucent area at the apex of a bicuspid that is causing pain makes diagnosis straightforward and recommended treatment predictable. Diagnosis and treatment become more complex and confounding when that tooth in pain does not demonstrate clear endodontic pathology.

AHI

Rating

Normal

5-15

Mild Sleep Apnea

15-30

Moderate Sleep Apnea

>30

Severe Sleep Apnea

30 DSP | Spring 2021

Dentistry isn’t alone in its desire for a clear recipe for decision making. Medicine needed guidelines for blood sugar levels in diagnostic and treatment decision making protocols for diabetes. With a long history providing significant relevant data, it was determined that normal blood sugar levels after fasting should be less than 100 mg/dL. But it is known that normal blood levels vary, and that patients may have pre-meal blood levels that range anywhere from 60 to 90 mg/dL. The normal levels that vary for each patient have an effect on what level for each of those patients is indeed pathological. What A1C levels are required for atherosclerotic changes or altered pancreatic function to be noted? It is clear that each patient’s adaptive capacity is indeed different, and that numbers obtained from a blood sample at one given time alone can’t be used as a single definitive factor in treatment decision making. There is a similar hunger for a cookbook approach in sleep medicine. Sleep medicine needed factors to help determine whether a patient actually had Obstructive Sleep Apnea (OSA) and whether or not that diagnosed OSA should be treated. The expediency of this decision was then accelerated by insurance companies that were suddenly bombarded with a “new disorder” that required standards to determine what levels would qualify for payment. Sleep medicine is a relatively young field, and from its inception there was a realization that norms would be required to help

guide therapy. What would sleep medicine use to determine severity of the disease the way that mg/dL are used in determining levels of diabetes? Despite the fact that it was developed as a validated tool to quantify the hypersomnolence of narcolepsy, the Epworth Sleepiness Scale (ESS) became the “standard” to evaluate the hypersomnolence often associated with OSA.1 Insurance companies set a minimum standard that was required for treatment even though patients can be at severe risk for fatal cardiovascular accidents, for example, without being hypersomnolent. The ESS became the most commonly used screening tool despite the fact that it has been shown that there is poor relationship between the ESS and the likelihood of having OSA and its severity.2 This cavalier approach to establishing norms leads our profession to consider the glaring shortcomings of using Apnea Hypopnea Index (AHI) alone as a major factor in determining severity of disease. Therefore, its current use in guiding treatment is problematic. Several authors have recently questioned the use of AHI in this manner. In a recent personal communication, Dr. Larry Lockerman spoke of approaching Dr. Christian Guilleminault, a well-known researcher who was one of the early pioneers in sleep medicine and is credited with coining the term “obstructive sleep apnea.” Following a conference presentation, Dr. Lockerman asked Dr. Guilleminault how AHI became the determining factor in the diagnosis of OSA and how the number “5” was reached as the acceptable “norm?” Dr. Guilleminault told him that early in the development the insurance companies needed to know when a patient should be treated, so he “made up” the number 5 as the “norm” and the number 15 as that number which required treatment. Dr. Guilleminault admitted that he was “sorry” he did that.3 AHI is a measure of the number of respiratory episodes per hour during sleep. There

With over 600,000 patients treated, feel confident that the world leader in Oral Appliance Therapy is the partner you need to help quiet the noise of Obstructive Sleep Apnea.

Contact your local representative for more information. www.somnomed.com

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CLINICALfocus

No longer should patients titrated with…AHIs slightly over…“5” be advised that the appliance is “unsuccessful”…

are many variables the AHI does not consider that have resulted in peer reviewed literature demonstrating a lack of relationship between AHI and severity of the comorbidities associated with the disorder. The most obvious issue is the definition of a respiratory event itself. Medicare initially required an AHI of 20 for coverage. There was a point in time when Medicare played a major role in lowering the desaturation required to qualify as an event from 3% to 4%. But of course, there are other variables that need to be considered, including length of events, the degree of oxygen desaturation with each event, and the endotype or phenotype of the patient altering the effect of the desaturation on the cardiovascular system and other potential comorbidities. Lavie points out the importance of the age of the patient in treatment decision making as well.4 It becomes obvious that diagnosing the role of OSA’s effect on our unique patient’s health and using that information intelligently to contribute to the risk benefit quotient when determining appropriate treatment options is more complex than simply looking at a single variable. It isn’t surprising that there is no direct dose related response relationship between AHI and disease.5 Medicine and dentistry’s desire to use this cookbook formula should not be surprising. As Ralph Waldo Emerson noted when discussing the tendency to attempt to make sin-

Barry Glassman, DMD, has earned Diplomate status with the American Board of Craniofacial Pain, the American Academy of Pain Management, and the American Board of Dental Sleep Medicine. He is also a Fellow of the International College of Craniomandibular Disorders. Among his recent publications are The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients with Status Migrainosus in Headache, and The Curious History of Occlusion in Dentistry in Dentaltown. He teaches and lectures internationally on orofacial pain, joint dysfunction, and sleep disorders. Don Malizia, DDS, limits his practice to upper-quarter chronic pain and sleep disturbed breathing at the Allentown Pain & Sleep Center in Wilkes-Barre, Pennsylvania.

gle markers more meaningful than they may in fact be: “This reduction to a few laws, to one law, is not a choice of the individual, it is the tyrannical instinct of the mind.”6 An improved perspective on the role that AHI can play in our diagnosis and treatment planning should be celebrated – not feared and rejected. We need a more specific, realistic diagnosis with the presence of the disorder as well as the severity being recognized as the multivariable issue that it is. This will lead to improved diagnostically driven treatment planning more appropriate for the unique patient we are committed to helping. Elderly patients with no comorbidities and low level “pathological” AHIs should not be burdened with treatment that may not be required. No longer should patients titrated with oral appliance therapy and AHIs slightly over the normal level of “5” be advised that the appliance is “unsuccessful” and, despite being CPAP intolerant and in need of therapy, told to discontinue oral appliance use. Once these additional markers are appropriately adopted, sleep medicine will no longer be inappropriately dependent on a single factor, and each patient will have their medical history, their age, their phenotype, and the details of their obstructive events considered in the treatment decision making. Ralph Waldo Emerson would be proud. Authors’ note: The following review is suggested reading as it provides an excellent summary of the history of the concept of AHI and the current literature and lack of supporting evidence and validation. Pevernagie, D. A., B. Gnidovec-Strazisar, L. Grote, R. Heinzer, W. T. McNicholas, T. Penzel, W. Randerath, S. Schiza, J. Verbraecken and E. S. Arnardottir (2020). “On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal.” Journal of Sleep Research 29(4): e13066.

1. 2.

3. 4.

32 DSP | Spring 2021

Johns MW. Epworth Sleepiness Scale. 1991. Quan SF. Abuse of the epworth sleepiness scale. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2013;9:987. PersonalCommunication. Conversation with Dr. Larry Lockerman. 2021. Lavie P, Lavie L, Herer P. All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age. The European respiratory journal 2005;25:514-20. Pevernagie DA, Gnidovec-Strazisar B, Grote L et al. On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal. Journal of Sleep Research 2020;29:e13066. Emerson RW. Natural History of Intellect and other papers. Boston and New York: Houghton and Mifflin and Company, 1904.

BILLINGblocks

Remote Patient Monitoring Reimbursement – Medicare Leads But Will Private Payors Follow? by Randy Curran

ave you seen the documentary focused on the thriving wildlife ecosystem in Chernobyl? If you’re too young to remember what happened there, in 1986 an accident occurred at the nuclear reactor in Chernobyl and severe disaster followed, rendering the city uninhabitable by humans. The documentary doesn’t focus on the unspeakable horrors endured by the town’s human citizens. Instead, it centers on the robust biodiverse sanctuary flourishing sans human interference. There are now more wolves in the fallout zone than there are within hundreds of miles outside the fallout zone. You might be thinking, “Well, that’s great, Randy. Go write for National Geographic. This is Dental Sleep Practice.” 2020 was a tough year, particularly for those of us that own small or medium-sized businesses. Like the wildlife enclave flourishing in what had become a wasteland, there are also longterm positive changes we’ll experience as a result of the COVID catastrophe. As Milton Friedman famously said, “Only a crisis – actual or perceived – produces real change.” This certainly applies to telemedicine as Medicare and private carriers got behind the importance of patients having access to care whether in person or via virtual platform. This convenience and the insurance coverage for it, are unlikely to disappear any time soon, if at all. We continue to see telemedicine visits covered with consistent reimbursement payments. The coverage and parity laws are actively being discussed in many state legislatures as they seek to lessen burdens on their constituencies (and win votes). Another lasting silver lining is the rising adoption of wearable technology and remote patient monitoring. You have seen the Fitbit-style wrist bands, the continuous monitoring ring-style pulse oximeters, and the Apple Watch that now tracks oxygen levels. This technology is developing so rapidly that by the time this article is published, there will

34 DSP | Spring 2021

probably be another 500 products on the market. Of particular interest, Itamar Medical recently acquired the impressive technology of Spry Health. As someone with sleep apnea and hypertension, I periodically use my recordable pulse ox to ensure I’m doing well on my therapy, but let’s be honest, “periodically” is every 3-4 months. According to my loving wife, who is a Respiratory Therapist in the ICU, I’m not paying enough attention to my own outcome. I should probably listen to her more often (I hope she doesn’t read this). Now, let’s dig deeper into the real-world applications of these technologies in a dental sleep practice. Some of the most well-known software engineers in our country are committing their brain trust to develop platforms that will enable these innovative devices to automatically communicate results to healthcare providers via cellular networks. This also meets the medical billing requirement stipulating that the data may not be self-reported by the patient with uploads and email transmissions but instead must be digitally reported directly to the provider. Additionally, this will be exceedingly beneficial to set up a system that will identify patients in need of recall appointments with a dashboard view for the clinical staff. It will also be far more efficient and cost-effective. Medicare has recently rewritten the coding and final rule on remote patient monitoring. On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized new policies related to remote patient monitoring for 2021. Here’s an excerpt from Medicare’s final ruling update: “Beyond acknowledging the CPT specification that the medical device supplied for CPT code 99454 must meet the FDA definition of a medical device, we are clarifying that the medical device should digitally (that is, automatically) upload patient physiologic data (that is, data are not patient self-recorded and/or self-reported). We note also that

BILLINGblocks use of the medical device or devices that digitally collect and transmit a patient’s physiologic data must, as usual for most Medicare covered services, be reasonable and necessary for the diagnosis or treatment of the patient’s illness or injury or to improve the functioning of a malformed body member” One of the great new additions of this rule is that the staff of the provider may monitor the data and work directly with the patient, while allowing the provider to bill for the service and be compensated for delivering a higher level of patient care. This also includes allowing third party services to monitor these patients and report back to the provider. History has shown that what Medicare does, private insurance usually follows as many private insurers have to play by Medicare’s rules with the Medicare replacement plans they provide. Also, there are already rules in place in 13 states that address some type of remote patient monitoring, and we will see this continue to rise as the topic has the backing of both the American Medical Association and the American Heart Association. What does all this mean for you? Hopefully you are as excited as I am about the new technology that will improve patient care while efficiently allowing providers to monitor the treatment outcomes on an ongoing basis to ensure their patients are breathing well during their sleep. A little icing on the cake will be the private carriers following Medicare’s lead and consistently reimbursing for this new care paradigm. Remote patient monitoring codes currently exist. Here are the basics: 99453 – Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment 99091 – Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days 99454 – Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days 99457 – Remote physiologic monitoring

treatment management services, clinical staff/ physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/ caregiver during the month; first 20 minutes 99458 – Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure) What should you do after reading this article? Find a device that does the following: 1. Continuously monitors your patient’s oxygen levels during sleep 2. Transmits the data back to you directly via cellular method without requiring the patient to upload and email the report. 3. Provides a software dashboard to easily track patients. Once you identify the device that is a good fit for your practice, give the next 5-10 patients the device and then follow the protocols for setup and monitoring. Bill the set-up code right away to the insurance carrier, and then the collection of data, monitoring and patient engagement codes to the insurance carrier after you have gathered and reviewed the results with your patient. Our company, Pristine Medical Billing will be billing this first round of test patients free of charge for our clients. This coverage is very new, and Medicare has just released the new final rule, so be patient with the process while the private insurance carriers start to come on board. The only way we ever truly know the results with these new parameters as a dental practice, is to dive in and start billing it to the carriers. Chernobyl. Thriving wolf populations. Telemedicine. Remote patient monitoring and new codes. Just another day at the office.

The staff of the provider may monitor the data and work directly with the patient…

Randy Curran is the founder and CEO of Pristine Medical Billing. During the past 12 years, Randy has committed his life to helping those with sleep related breathing disorders obtain prior authorizations for coverage while ensuring providers receive fair compensation for care. Randy has been involved in the treatment of more than 38,000 patients while collecting over $85,000,000 for providers from insurance carriers through both contracting and claim submissions.

DentalSleepPractice.com

PRACTICALtips

DME

Durable Medical Equipment or Dental Medical Expertise?

by Jamison Spencer, DDS, MS

urgeons don’t get reimbursed based on the cost of their scalpel blades and sutures.

Get prepared now for the launch of oral appliance therapy “direct to consumer” campaigns.

36 DSP | Spring 2021

But that’s what dental sleep medicine providers are paid for – for the appliance – for giving someone a piece of plastic. We are NOT paid for our skills or expertise. As “Durable Medical Equipment” providers, we dispense durable medical equipment under an Rx from an MD. The problem with how dentists are compensated in the U.S. and many other countries is that insurance companies pay for delivery of an appliance; a piece of plastic, acrylic, or nylon that has been cleared by the FDA because it looks like other appliances that have been previously cleared. Treating patients with sleep disordered breathing issues involves far more than the appliances we select. The ongoing pandemic has even been cited as justification for mailing the pieces of plastic directly to patients for them to deliver themselves. There are certainly instances where this is indicated, appropriate, and medically necessary. However, there are already myriad reports of unscrupulous groups taking advantage of this limited use loophole to bill for “delivery” of the oral appliance, without providing any pre/post-care. Get prepared now for the launch of oral appliance therapy “direct to consumer” campaigns. If a patient is deemed capable of handling their own orthodontic care, I assume there will be those investors who will believe such consumers are qualified to handle their own oral appliance therapy as well. I blame the insurance companies and Medicare for this. They have set up the system, and we are trying to work within it. Why

do we even try to work within their system? Because we’re trying to help as many people as we can, and for many of our patients, insurance or Medicare coverage is important. While we continue to toil to get insurance companies to understand the immense benefit our experience, education, and expertise can provide patients via oral appliance therapy, we do need to ensure that we’re delivering oral appliances that are best indicated for each patient presentation. I’ll step off the soapbox and use it as a lectern. In the Spring 2020 issue of Dental Sleep Practice, I wrote an article titled “The 3 Most Common Mistakes with Oral Appliance Selection.” I encourage you to revisit that article and check it out, but here’s a quick overview. The 3 most common mistakes discussed were: 1. Choosing an appliance that does NOT allow adequate lateral movement for a patient with evidence of historical lateral bruxism. 2. Selling the appliance that you think will be the hardest for the patient to break. 3. Falling victim to the “n of 1 syndrome.” As a continuation of that article, I’ve been asked to write a little more about appliance selection, and in this issue, I’ll delve into some of the less common, yet incredibly important, considerations. I segment the numerous appliances into 5 groups based upon mechanism of action. Those groups include: • Anterior Pull/Push (TAP, MDSA, etc.) • Bilateral Push (Herbst-style) • Bilateral Pull (EMA, Silent Nite, etc.)

PRACTICALtips • Interlocking (Dorsal, ProSomnus, etc.) • Mono Block (Moses, Klearway, etc.) In general, certain types of mechanisms are better or worse for certain types of issues. Let me group some of the considerations into a few categories, and then briefly discuss each: • Retention • Patient preferences and convenience • Prior experience • Metal “allergy” • TMJ problem

Retention Retention related issues typically involve poor retention due to missing teeth and/or short clinical crowns. When poor retention is likely, it’s better to choose an appliance whose upper and lower components aren’t connected, such as an interlocking style appliance (an appliance with “fins” of some sort), or a push style appliance (such as a Herbst). Often dentists will look at a Herbst-style appliance and think that when the patient opens wide it would dislodge, but there is virtually no resistance to opening with a Herbst (unless elastics are used) and the patient would have to open really wide before the pistons will lock out, which rarely occurs.

Patient Preference and Convenience Under this category are things like the patient’s desire to be able to open their mouth fully because they’ll feel claustrophobic if they can’t, or technically merinthophobic – fear of being bound (thank you Dr. Rob Rogers for teaching me that). Other patients want the appliance to prevent mouth opening as they’ve found this was the problem in the past (particularly as they tried to use their CPAP). The anterior pull/push style is a great choice for patients who want to keep their mouth closed, but other appliance designs may also be used with the addition of vertical elastics. For the patient who desires the ability to easily open their mouth an anterior pull/push style is not the best choice.

…no self-repecting dental sleep medicine expert could possibly use such a “crappy appliance”

Some patients may have a harder time coming in for follow-up due to distance of travel, transportation, or mobility issues. For such patients it may be prudent to provide an appliance that doesn’t require as much in-person follow up or exchanging of parts. For example, a pull appliance may be suboptimal because of the need to replace bands/straps. This can be done via mail if necessary. The patient’s manual dexterity and vision must also be taken into account, particularly if they will not be able to easily come in for calibration of the appliance. It’s easier to adjust the position on some appliances than others. Additionally, some appliance designs make them readily adjustable via a phone call or telemedicine visit. If the patient can’t adjust the appliance themselves, perhaps they have a family member or caregiver who can help them. Another consideration is future restorative dental care. Dentist #1 recently told me about a patient who was initially fit for a custom oral appliance by Dentist #2. Dentist #2 failed to contact Dentist #1, the patient’s dentist, in advance. The patient was already treatment planned for multiple restorations, but none of this was taken into account by Dentist #2 who fit the oral appliance. Neither the patient nor Dentist #1 were happy

Dr. Jamison Spencer is the director of the Centers for Sleep Apnea and TMJ in Boise, Idaho and Salt Lake City, Utah. He is an invited lecturer on the topics of dental sleep and TMD around the world. His “Spencer Study Club” is the premier, members only, education and mentoring forum for smart and ethical dentists looking to implement sleep and TMD in their practices effectively and profitably. For more practical and often irreverent information check out his podcast, “The Airway, Sleep & TMD Podcast.”

DentalSleepPractice.com

PRACTICALtips Anterior Push/Pull (TAP, MSDA, etc.)

Bilateral Push (Herbst-style)

Bilateral Pull (EMA, Silent Night, etc.)

Interlocking (Dorsal, Prosomnus, etc.)

Mono Black (Moses, Klearway, etc.)

Lateral Bruxer

certain styles

good

most styles not ideal

not ideal

Desire to keep mouth closed

good with good retention

good with elastics

good with good retention

good with elastics

good with good retention

Desire to allow for mouth opening

limited

good

somewhat limited

good

limited with good retention

Retention issues (short clinical crowns)

not ideal

good

not ideal

good

depends on style/liner/clasps

Difficulty returning for follow up

not ideal due to need to replace straps/bands

Metal allergies or sensitivities

most not ideal

good

depends on style

about this. It is usually not that difficult to plan ahead for pending restorative dentistry and to choose an appliance that may be easily modified or relined. You might even consider beginning with a temporary appliance when this situation arises.

Prior Experience I had a patient who’d previously been given a Herbst-style appliance. She hated it. And she’d tell you all about it. After getting to know her better and asking her a lot of questions, I realized that she didn’t despise the appliance. She deplored the dentist that gave it to her, and she had an overall negative experience at their practice. It really wasn’t the appliance. Still when I decided on the appliance to use in her case, I did NOT go with what she had been given in the past since she connected negative emotions with it. Another time a physician came to me. She had been given a boil and bite snore guard (literally the “Snore Guard” – which is a specific branded appliance) by her general dentist a year prior. Her dentist referred her to me to take over her care. I figured that no self-respecting dental sleep medicine expert could possibly use such a “crappy appliance,” so I guided her into custom-fabricated one. Guess what? She hated it! I ended up making her another Snore Guard and have made her several more over the years. I’m my experience, if a patient loves a certain appliance and they’d like a new one – just make it for them. They’ve become accustomed to it. They wear it. Isn’t that the goal?

38 DSP | Spring 2021

Metal “Allergy” This one is pretty obvious but frequently missed until it’s too late. Discuss any metal “allergies” with the patient if you’re thinking of using an appliance with metal. Why the quotation marks, my proofreading DSM gurus? Because many people who think they are allergic to metal aren’t actually allergic. HOWEVER, it’s not worth the battle to try to convince them otherwise, so I would rather choose an appliance that is metal-free.

TMJ Problem This one isn’t actually about the appliance but is more about your skill and expertise as a clinician. It’s about diagnosing what their “TMJ problem” really is. What will be required to treat it, if treatment is indicated at all? Did they previously have a problem, but they haven’t for years? Do they have an internal derangement, such as a reducing or non-reducing disc displacement? Do you know how to tell? Could their relatively mild problem get worse? Could their relatively severe problem get better with oral appliance therapy? Treating a patient with an existing or past TMJ problem is more about you than the appliance, however, depending on the diagnosis, there are certain appliance designs that would make more sense than others. That’s a topic for another article. Use these guidelines. Talk to your patients, their other providers and think critically.

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PRACTICEmanagement

Dental Marketing –

REFERRALS

Trump Everything by John Tucker, DMD, D.ABDSM, DICOI, and Elias Kalantzis

ot an extra $33 million lying around? That’s what Chanel paid for the most expensive advertising campaign of all time. More than $3 million of that budget was paid to the famous actor, Nicole Kidman.

...companies who maintained their investment in marketing through the Great Depression came out 20% ahead...

40 DSP | Spring 2021

Marketing and advertising are vital to a business’ success. However, during a down economy or uncertain times, it’s common for firms to cut back on marketing. Every successful businessperson, every entrepreneur, and every marketing company will tell you that is exactly what you should *NOT* do. Guess what? They’re right. In 1927, the Harvard Business Review (HBR) published an article showing that companies who maintained their investment in branding and marketing through the Great Depression came out 20% ahead of where they were at the start of the collapse. Before you chalk that fact up to a different time with a different business environment, an August 2020 article by Nirmalya Kumar and Koen Pauwels in HBR stated, “Companies that have bounced back most strongly from previous recessions usually did not cut their marketing spend, and in many cases actually increased it.” This principle hasn’t changed in nearly 100 years. Increasing marketing spend has been proven to multiply profits during troubled times. It seems counter-intuitive. Let’s take a look at how advertising costs are determined by supply and demand. We’ll demonstrate it with a quick thought experiment. If you were

going to place radio ads 3 weeks before a November election, would air time cost more in October or January? Of course it will be more expensive in October because the demand is high and the supply is low. During tough economic times, the supply is higher and the demand is lower which means you can stretch your current marketing dollars further. Due to the higher supply and lower demand, every dollar you spend in excess of your current budget will therefore exponentially increase profits. Simply stated – You get more bang for your buck. So, what kind of marketing should you invest in? Perhaps a new website, Facebook ads, or Instagram. Maybe SEO, PPC, SEM, LMNOP? There is no doubt that online advertising is effective, scalable, and available. However, dentists aren’t online marketers. We’re dentists. So, what’s the problem? Just hire an online marketing firm, right? Ah, the innocence of ignorance. When hiring an online marketing firm it’s up to you to make decisions about whether you want your website to be dynamic/mobile friendly. The onus is on you to consistently create new engaging content, to be active on social media, to engage social media followers, determine which platforms to advertise on, establish your adwords budget, and figure out how to get positive reviews and glowing testimonials. Identifying the right digital marketing partner is a slog. You’ll need to vet, interview, and hire the company and then cross

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PRACTICEmanagement

...people pay 200% more attention to recommendations from friends, and referred patients bring in 25% higher profit margins.

your fingers hoping for a desirable return on investment (ROI). In fact, most practices cycle through an average of 4 online marketing companies before experiencing any semblance of desirable ROI. Unfortunately, due to variability of gatekeeper algorithms, even those companies who specialize in this area struggle. The average cost for a small business’s successful online adword campaign is over $10k per month. Again, there are benefits to online advertising and you should certainly have a presence, but perhaps there are other ways to maximize your marketing efforts. Let’s look at some offline marketing strategies. Do you scan every single email you receive? Do you actually look at every paid ad that pops up on your screen? 86% and 78% respectively, answered negatively to these two questions. Conversely, do you go to your mailbox, bring the mail in and mindlessly dump it into the recycle bin or do you first flip through each item – even if only briefly? After scanning each item and realizing that much of it is actually junk, then, and only then, do you discard it. If you’re like most, you probably regard direct mail as mere junk mail. When developed, designed, distributed, and tracked properly, it’s not trash. It’s treasure. It’s effective, personalized, memorable, and trackable. Pay attention to your mailbox. You probably receive 2-3 postcards from different dental practices. They’re interchangeable. They look the same. They sound the same.

They probably even have similar offers and – surprise, surprise – they are now accepting new patients. Or maybe the offer is for “FREE cleaning, FREE xrays, FREE exam” which sounds more like a monster truck rally than how most dental practices want to be perceived. Additionally, when the emphasis is on giving away free treatments, it’s no wonder these promotions attract low value, price-shopping patients which leads to more churn. The cycle continues. Maybe you get those envelopes with a ream of coupons or ads in them. They are usually stuffed with 50 businesses and an average of 5 dental practices. That means your practice is sandwiched between the local bistro and carpet cleaning. Is this what you want? No, your practice is a standout, but it’s not standing out. According to the US Small Business Administration, “Direct mail campaigns generate purchases five times larger than email campaigns. Combining email with direct mail led to the best results of all: purchases six times larger than email alone generated.” Most marketing companies that offer both online and offline marketing will admit this little known fact. Not convinced? In the same way digital-first companies such as Warby Parker and Glossier have begun opening physical stores to create a special experience, sending physical mail is a way to stand out from the crowd. Direct mail has been proven to be more shareable and have a longer life-span. Retail Wire’s 2019 study found that email has a lifespan of just a few

John H. Tucker, DMD, DICOI, D.ABDSM, has maintained a private practice in Erie, Pennsylvania since 1982. He is a graduate of the University of Pittsburgh School of Dental Medicine. Dr. Tucker has a special interest in the treatment of Obstructive Sleep Apnea. As a Diplomate of the American Board of Dental Sleep, he is exceptionally qualified to manage this serious problem with Oral Appliance Therapy. He has been actively treating patients in the Tri-State Erie area for the past ten years. Dr. Tucker founded Erie Dental Sleep Therapy, LLC, in 2007. Erie Dental Sleep Therapy, LLC, became the eighth AADSM Accredited facility in June of 2012. Dr. Tucker is passionate about educating the dental profession; he has presented approximately 1,700 hours of continuing education on treating the PAP intolerant patient with Oral Appliances Therapy nationally and internationally over the past six years. Dr. Tucker has also published numerous articles regarding Oral Appliance Therapy for OSA patients that are unable to tolerate PAP therapy. Elias Kalantzis is the founder/co-founder of numerous businesses that have become household names in the Dental Sleep Medicine industry including OSA University, Pristine Medical Billing, Transform Dental Sleep, and SleepTest.com. He is a graduate of the University of Illinois at Urbana-Champaign. Elias has an extensive background in marketing and business development in the dental industry. His personal mission is to spread awareness of sleep-related breathing disorders, the health consequences when left untreated, and alternative treatment options. Off hours, Elias enjoys fishing, cooking, playing chess, refining his winemaking skills, and spending time with family and friends.

42 DSP | Spring 2021

PRACTICEmanagement seconds, while direct mail’s average lifespan is 17 days. The key differentiating factor with direct mail is you must grab the recipient’s attention. Creating a compelling offer is as important as utilizing high quality printed material. Consider printers that offer paper in various weights and sizes, as well as high gloss, embossments, and foil printing options. Taking this “Tactile” approach to your marketing collateral, will undoubtedly make you stand above the crowd. The better the quality, the more memorable your ad will be, and the greater your chances will be to acquire new patients. Also consider the importance of referral marketing. We all search online for restaurants and pay close attention to customer reviews. 93% of respondents to a Trip Advisor survey said they have perused online reviews when making a dining decision. In that same survey, 99% of respondents said they visited a restaurant based on the personal suggestion of a friend or family member. Now, let’s pivot to your practice. Which patient is more valuable to your practice – one that you obtain through a Facebook ad or one that comes via a patient referral? Have you created a successful patient referral sys-

tem that allows your patients to invite their friends and family to your practice? Why not? A recent Dental Economics article showed that 92% of consumers trust recommendations from people they know, people pay 200% more attention to recommendations from friends, and referred patients bring in 25% higher profit margins. There are marketing companies, like Viva Concepts, that print high quality referral gift cards that you can hand to your patients. Out of several hundred dental offices that utilize their “care-to-share” patient referral program, the average response rate is 5.1%. That response rate by far exceeds any online or offline marketing. Aside from beautifully printed referral gift cards, Viva offers a dashboard to track your results and identify where your patients are coming from. Whether you use an outside service or create your own internal system, obtaining high conversion patient referrals it’s an absolute must. Lastly, when enacting your 2021 practice strategy, remember that marketing is an investment and not an expense. Like any investment, the time to buy is when prices are low. To quote Warren Buffett, “Be fearful when others are greedy, and greedy when others are fearful.”

“THE ZZZ PACK” PODCAST

The prescription for dental sleep we have all been waiting for. Uncensored, real talk with hosts… Lisa Moler: DSP Publisher, Sleep Apnea Slayer, and Patient Dr. Erin Elliott: The fearless OSA doctor aka “The Queen of Good Air” Jason Tierney: Multi-syllabic thought provoker in all things sleep Listen now at www.zzzpack.com

DentalSleepPractice.com

PEDIATRICS

Face Facts: Function that Builds the Airway by Sharon Moore

n part three of this four-part series, author, speech pathologist and myofunctional practitioner Sharon Moore shares critical information about the role of myofunctional therapy in the management of pediatric sleep disordered breathing. Previously, we looked at how dental clinics can screen for sleep disordered breathing for early treatment, with the goal of addressing problems well before children start school.

In this article, we will look at the role of myofunctional therapy in building and maintaining a healthy airway in a proactive, family-friendly way. Four-year-old Daniel had turned into a monster. Daniel had been a poor sleeper from birth. He refused to go to bed, woke his parents frequently, and only had seven hours of sleep a night (instead of the recommended 10-13 hours for his age). He never slept for more than two hours at a stretch and wouldn’t take naps in the day. Like many sleep-deprived kids, every day Daniel would hit the ground running, reacting to sleep deprivation with over-activity, which the body craves as compensation for poor sleep. Not only that, but Daniel had an explosive temper and was extremely defiant. After two years of Daniel’s irrational meltdowns, and seeing 23 specialists in Australia and the US, his parents were at a breaking point (and so was their marriage). It wasn’t until a dentist recognized an airway/breathing issue in a routine check-up, that they were referred to me. After six months of medical, dental, and myofunctional therapy (myo) treatments, Daniel was a brand-new kid; he was breathing and eating well with no more snoring or tantrums, and he had a big growth spurt. His improvement was measurable on the Sleep Disturbance Scale for Children,1 where his scores almost halved from ninety-nine in March 2016 to fifty in December 2016, placing him in the normal range.

The 3 Biggest Problems for Parents of Sleep-wrecked Kids

As a speech pathologist diagnosing and treating “things that go wrong in the upper airway”, I’ve seen first-hand how sleep problems interfere with kids’ health, communication, and family happiness. Unfortunately, many sleep-breathing problems are missed, dismissed, or misdiagnosed. While parents may notice symptoms, many assume they are normal, or they might

44 DSP | Spring 2021

PEDIATRICS

be so busy they focus on quick fixes rather than addressing underlying issues. Additionally, sleep is such a specialized area of medicine that many doctors don’t know how to address it.

Dentists are on the Front Line

Dentists are in the best position to screen for, educate on, and treat problems like sleep disordered breathing (SDB), given that they work face-to-face with families and children. 1. For parents seeing symptoms but not recognizing them, dentists can provide educational guides and screening.2,3 2. For parents focused on quick fixes, dentists can give feedback on the best treatment options: medical, dental, myo or all three.4-6 3. For parents needing medical or dental expertise, dentists can refer them to a network of likeminded professionals.7-11

One of the reasons why our kids might struggle to sleep relates to evolution and how the shape and size of the human mouth, jaw and airways have changed over time...

What Leads to Poor Upper Airway Patency?

You have far more influence over the shape and development of children’s airway health than you might believe.12 Aside from clearly diagnosable medical conditions, syndromes, and craniofacial anomalies, there are many non-syndromic children developing airway issues.13 This is often due to shifts in modern-day life leading to changes in how children’s faces, mouths, and airways develop.

Sharon Moore is an author, speech pathologist and myofunctional practitioner with 40 years of clinical experience across a range of communication and swallowing disorders. Sharon has a special interest in early identification of craniofacial growth anomalies in children, concomitant orofacial dysfunctions, and airway obstruction in sleep disorders.

DentalSleepPractice.com

PEDIATRICS The way we use the muscles for sucking, swallowing, breathing, and chewing – especially in our early years – has a big impact on breathing during sleep, and subsequently sleep quality.14 Our jaws rely on optimal muscle function to grow and develop. For

Jenna before a ‘myo correct’ treatment program

Jenna after 6 weeks of ‘myo correct’ treatment – sometimes results are stunningly fast

46 DSP | Spring 2021

this reason, it’s important to ensure children learn to use these muscles correctly.15 If sub-optimal muscle use is not fully treated, recurrence or development of SDB is even possible later in life.16

Myo: The Secret Weapon to Fighting the Sleep Crisis?

There are multiple studies demonstrating the crucial role of myofunctional therapy (myo) in the management of SDB. A recent study shows that Apnea-Hypopnea Index can be reduced by 43% in children with myofunctional therapy.17 Other studies support this premise.18-23 This tells us sleep breathing problems are both treatable and avoidable. There are two ways we use myo in our clinic: 1. Myo optimize programs for children, like a fitness program for the mouth, face, and throat. 2. Myo correct for addressing existing issues, which entails functional assessment, diagnosis, and corrective treatments. The ultimate aim is for ‘myo fitness’ to be a part of everyday life.

PEDIATRICS

Who is ‘Qualified’ to do Myofunctional Therapy?

There is almost always a role for a welltrained and experienced myofunctional practitioner in managing a child’s upper airway health. Protocols and the body of knowledge in myofunctional science are rapidly growing. It is a sub-specialty for existing health professionals, including speech language pathologists, occupational therapists, physical therapists, and dental hygienists. With telehealth, myo has become accessible to all, opening potential global partnerships with experienced practitioners.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Why Wait for Great Sleep?

Left untreated, poor breathing, sucking, chewing, and swallowing habits may lead to shape changes in face and jaws that go on to shape the adult face, jaws and airway, predisposing children to SDB for life. Consequently, proactive early intervention is the key. If we tune into these problems well before children start school, they can recover from deficient or poor growth and development patterns into a typical growth pattern. When children’s sleep and breathing improves, they are happy, alert and better behaved within days. Having a healthy airway from a young age can save a lot of trouble later.

15. 16. 17.

18.

19.

20. 21. 22.

23.

Oliviero Bruni, Salvatore Ottaviano, Vincenzo Guidetti, Manuela Romoli, Margherita Innocenzi, Flavia Cortesi and Flavia Giannotti, ‘The Sleep Disturbance Scale for Children (SDSC): Construction and Validation of an Instrument to Evaluate Sleep Disturbances in Childhood and Adolescence’, Journal of Sleep Research 5, no. 4 (1996): 251–61, https:// doi.org/10.1111/j.1365-2869.1996.00251.x. Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing 2019). Sharon Moore, ‘Well Slept Kids’, guides for parents, in press, to be released 2021, queries: projects@wellspoken.com.au Guilleminault and Huang, ‘From Oral Facial Dysfunction to Dysmorphism and the Onset Of Pediatric OSA’ Christian Guilleminault, ‘A Case for Myofunctional Therapy as a Standard of Care for Pediatric OSA’, in The2nd AAMS Congress (Chicago, 2017). Guilleminault, Christian, et al. “Teenage sleep-disordered breathing: recurrence of syndrome.” Sleep medicine 14.1 (2013): 37-44. AAPMD: American Academy of Physiological Medicine and Dentistry, https://www.aapmd.org TBI: The Breathe Institute, https://www.thebreatheinstitute.com AAMS: Academy of Applied Myofunctional Sciences, https://aamsinfo.org IPOS: The International Pediatric Orthodontic Society, https://iposinfo.org/contact/, https://fr.iposinfo.org IAOM: International Association of Orofacial Myology, https://www.iaom.com Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing 2019). Linda D’Onofrio, Oral dysfunction as a cause of malocclusion, Orthod Craniofac Res. 2019;22(Suppl. 1):43–48, DOI: 10.1111/ocr.12277 Christian Guilleminault and Yu-Shu Huang, ‘From Oral Facial Dysfunction to Dysmorphism and the Onset Of Pediatric OSA’, Sleep Medicine Reviews, 2017, https://doi.org/:10.1016/j. smrv.2017.06.008. Christian Guilleminault, ‘A Case for Myofunctional Therapy as a Standard of Care for Pediatric OSA’, in The 2nd AAMS Congress (Chicago, 2017). Guilleminault, Christian, et al. “Teenage sleep-disordered breathing: recurrence of syndrome.” Sleep medicine 14.1 (2013): 37-44. Anuja Bandyopadhyay, Kellie Kaneshiro, Macario Camacho Effect of myofunctional therapy on children with obstructive sleep apnea: a meta-analysis, Sleep Medicine, Volume 75, November 2020, Pages 210-217, https://doi.org/10.1016/j. sleep.2020.08.003 Macario Camacho, Victor Certal, Jose Abdullatif, Soroush Zaghi, Chad M. Ruoff, Robson Capasso and Clete A. Kushida, ‘Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis’, Sleep 38, no. 5 (2015), https://doi.org/10.5665/sleep.4652. Camila De Castro Corr.a and Gi.dre Berretin-Felix, ‘Terapia miofuncional orofacial aplicada. S.ndrome do aumento da resist.ncia das vias a.reas superiores: caso cl.nico’, CoDAS 27,no. 6 (2015), https://doi. org/10.1590/2317-1782/20152014228. C. Guilleminault, Y. S. Huang, P. J. Monteyrol, R. Sato, S. Quo and C.H. Lin, ‘Critical Role of Myofascial Reeducation in Pediatric Sleep-Disordered Breathing’, Sleep Medicine 14, no. 6 (2013), https://doi.org/10.1016/j.sleep.2013.01.013. Huang and Guilleminault, ‘Pediatric Obstructive Sleep Apnea and the Critical Role of Oral-Facial Growth: Evidences’ Macario Camacho, Christian Guilleminault, Justin M. Wei, Sungjin A. Song, Michael W. Noller, Lauren K. Reckley, Camilo Fernandez-Salvador and Soroush Zaghi, ‘Oropharyngeal and Tongue Exercises (Myofunctional Therapy) for Snoring: A Systematic Review and Meta-Analysis’, European Archives of Oto-Rhino-Laryngology, 2017, https://doi. org/10.1007/s00405-017-4848-5. Maria Pia Villa, Melania Evangelisti, Susy Martella, Mario Barreto and Marco Del Pozzo, ‘Can Myofunctional Therapy Increase Tongue Tone and Reduce Symptoms in Childrenwith Sleep-Disordered Breathing?’ Sleep and Breathing 21, no. 4 (2017), https://doi.org/10.1007/s11325-017-1489-2.

DentalSleepPractice.com

EDUCATIONspotlight

Dental Sleep Medicine Education at Tufts University by Leopoldo P. Correa, BDS, MS, D.ABDSM

ental sleep medicine has evolved rapidly during the last few years thanks to the advancement in research related to the use and efficacy of oral appliance therapy. Oral appliances assist in maintaining the mandible forward during sleep to prevent the collapsibility of upper airway muscles. However, the resultant advancement of the lower jaw in some patients may produce discomfort or pain in the masticatory muscles, temporomandibular joint (TMJ), and head and neck areas.

“With a collaborative spirit between academic institutions and professional associations, we are advancing the field of dental sleep medicine globally.”

Current clinical guidelines recommend that following diagnosis and referral from a physician, qualified dentists can use oral appliances among patients with mild to moderate OSA or in particular cases of severe sleep apnea in which patients are noncompliant with or unable to use positive airway pressure therapy. Clinical techniques, such as the use of morning jaw aligners and the performance of jaw exercises, have been developed to minimize occlusal symptoms during oral appliance therapy; however, these approaches require further research to confirm their validity and long-term efficacy. When the National Institute of Medicine published “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem,” it ushered in a new way of looking at Somnology and Sleep Medicine, prompting its inclusion in academic curriculums. Tufts Universi-

Leopoldo P. Correa, BDS, MS, is committed to supporting academic learning as well as clinical practice and has worked as a faculty member at the Tufts University School of Dental Medicine Craniofacial Pain Center, Department of Diagnostic Sciences for more than 15 years. Dr. Correa is Associate Professor, Director of the Dental Sleep Medicine Programs at Tufts University School of Dental Medicine. He is a Diplomat of the American Board of Dental Sleep Medicine and received his Master’s of Sciences Degree at Tufts University. Dr. Correa teaches Dental Sleep Medicine to the pre- and postgraduate programs at Tufts University and has participated as a speaker in the United States, Europe, Asia, and Latin-America. To contact Dr. Correa, please email Leopoldo.correa@tufts.edu.

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ty Dental School is a pioneer in incorporating the teaching of Dental Sleep Medicine into its pre- and postgraduate curriculums, developed the first fellowship program in Dental Sleep and the longest running continuing education mini-residency programs. Dentists from around the world have attended our Dental Sleep programs and we have assisted in expanding the field of Dental Sleep Medicine globally. As dental sleep medicine continues to grow, it is essential that dentists who use oral appliances for OSA also understand the management of side effects, including occlusal symptoms, Temporomandibular Disorders, and adhere to current standards of dental sleep medicine practice. With the recent development of dental sleep medicine standards and the collaboration between academic institutions and professional associations, the practice and teaching of dental sleep medicine will continue to grow globally. To learn more about Tufts University Dental Sleep Programs, visit dental.tufts. edu/ce, email dentalce@tufts.edu, or call 617.636.6629.

DENTAL SLEEP

MEDICINE Mini-Residency 2021-2022

Boston, Massachusetts, USA Tufts University School of Dental Medicine’s Dental Sleep Medicine Mini-Residency is a 6-month program where participants engage with world-renowned experts in the field in live lectures and workshops, both online and in person. Between modules, program directors provide guided self-study, shorter monthly lectures, and mentorship.The live portions of this program are split into three 3-day modules:

Module I: Live-Streamed Online October 14 -16, 2021

Module II: On Campus

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January 20 -22, 2022

Module III: On Campus April 7- 9, 2022

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Registration open! Space is limited.

dental.tufts.edu/CE

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TMD & Orofacial Pain Mini-Residency Program

6 Modules, Live-Streamed Online and On Campus September 2021 - April 2022

Pediatric Dental Sleep Medicine Mini-Residency Program

Further questions, please contact dentalce@tufts.edu or 617-636-6629

Module I:Three 1-Day Live-Streamed Online Sessions Module II: One 3-Day On Campus Session November 2021 - March 2022

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

EDUCATIONspotlight

One Investment Guaranteed to Pay Dividends by Samuel Cress, DDS

ow many times have you spent hundreds or thousands of dollars on a course, sat through two days of mealy educational content, (sub)continental breakfasts, and pushy sales presentations? We’ve all done it. It’s like a rite of passage for dentists. We sit through a course listening to elementary lectures that minimize science and promote anecdotes while highlighting a handful of oral appliances. If you are unlucky enough, you have to listen to the lecturers talk about their boats, fishing stories, or their kids – all as a setup to sell you some product or service you don’t really need. Then you head back to the office Monday. Miraculously, your interest is piqued enough that you really want to make DSM part of your practice but guess what! No one else shares your ebullience, there’s an emergency in op 2, and your enthusiasm is depleted. You do it again a couple months later expecting different results, to no avail. Stop the insanity! As dentists, we cannot do what we do if we don’t have a great team alongside us. Developing a team can be challenging in the short term but immensely rewarding in the long run if you grant autonomy, provide them with the necessary training and resources to be rock stars, and actively involve them in the decision-making process. Engage your team in your goal-setting process. If your goal is to integrate DSM into your practice, then there are numerous introductory opportunities available across the country. Or maybe you are looking to transition your entire practice into a comprehensive dental sleep practice. Whatever the vision, there is a course that supports the next step for you and your team. The Nierman Practice Management (NPM) team of specialists can assess your practice and guide you in selecting the correct DSM educational of-

Samuel E. Cress, DDS, director of The Center for Craniofacial & Dental Sleep Medicine located in Houston, Texas, received his Bachelor of Arts Degree from Austin College in Sherman, Texas. He completed his Doctorate of Dental Surgery from the University of Texas Health Science Center, San Antonio, Dental Branch. Dr. Cress also completed his residency in Dental Sleep Medicine at Tufts University School of Dental Medicine in Boston and his residency in TMD through the American Academy of Craniofacial Pain. In addition to his practice specializing in dental sleep medicine, TMD, cosmetic and Full Mouth Rehabilitation, Dr. Cress is a clinical instructor where he teaches other dentists the benefits of Airway Conscious Dentistry as well as diagnosis and treatment of patients suffering from TMD. Dr. Cress currently holds a duel patent on an oral appliance, the Meridian PM, for the treatment of OSA and TMD, recently granted FDA clearance. Dr. Cress has several published articles in the field of Dental Sleep Medicine and has presented at the TMJ Bioengineering Conference in Barcelona, Spain.

50 DSP | Spring 2021

ferings to meet you where you are and take you where you want to go. From introductory DSM courses or cross-coding and medical billing courses to hands-on TMD and DSM opportunities and mini-residencies, NPM has courses that will turbocharge you and your team. The Center for Craniofacial and Dental Sleep Medicine (CFDSM) has partnered with Nierman Practice Management to offer a unique, impactful hands-on learning experience focused entirely on how to make DSM a productive, profitable, implementable piece of your practice. The two-day hands-on implementation experience is customized for you and your team. You will learn a team approach that will give you the tools to treat your guests suffering with OSA. This course exposes you to oral appliance therapy as a treatment option for OSA and provides an introduction to the Meridian PM, a unique dual appliance for the treatment of TMJ disorders and OSA. We’ll take bite registrations, personal home sleep tests with interpretations, and appliance deliveries with titration. NPM will demonstrate the ins and outs of medical billing, documentation, and software for medical reimbursement. Your practice will be elevated to the next level. If you are looking for an investment that will pay dividends throughout your career in DSM by changing lives through the world of dentistry, this course should be next on your schedule. Align with your team. Take back Mondays. Deliver great sleep. For more information on this unique educational experience or the Meridian PM, contact Nierman Practice Management at 800-879-6468 or The Center for Craniofacial and Dental Sleep Medicine at 281500-4200.

COMPANYspotlight

Who We Are: 3DISC

ounded in 2007, 3DISC started as an R&D company but quickly matured into an agile American manufacturer and global provider of digital imaging solutions for dental practices. Fourteen years later, 3DISC is a privately-owned company with headquarters based in the United States and France with a diverse team of digital experts curated from a variety of hightech backgrounds for one mission; to pioneer the digital dentistry landscape of tomorrow. Our goal is to deliver relevant clinical benefits to doctors through inclusively digital solutions, specifically intraoral scanners. When dental clinics choose 3DISC, they’re taking digital beyond; they can trust our commitment to the continuous innovation of our solutions that will help bring simplicity to their workday and empower doctors to provide the highest quality treatment to their patients. That’s why we created the Heron IOS. Solution Overview

The Heron IOS is a digital 3D imaging solution bringing simplicity to the beauty of your work as a medical professional. One of the most ergonomic and easy to use scanners on the market, the Heron weighs in at 150 grams with a compact, streamlined design for more efficient scanning and increased patient comfort. For an all-inclusive price, the Heron IOS is presented as a turn-key solution that takes less than 10 minutes to unbox and set up; including a pre-calibrated scanner, 3 autoclavable tips, and optimized acquisition PC equipped with HeronClinic software. Using the HeronClinic software, your team can easily navigate the intuitive,

52 DSP | Spring 2021

user-friendly interface to meet all your restorative, orthodontic, and implant needs. With clear workflows and a cloud sharing platform, the Heron IOS makes it easier than ever to create or browse patient cases, scan, and share with your labs. Our team is committed to providing superior service and support, so you can trust that when you introduce a Heron IOS into your practice we will be there providing thorough in-office training as well as a variety of online resources. Our optimized acquisition PC automatically deploys software updates as they are released to ensure you always have the latest as well as instant remote access capabilities when you have questions or need help.

Why Go Digital

Digital impressions have a number of advantages over traditional techniques. The increased accuracy of a digital impression results in fewer lab remakes and better fitting crowns and appliances. Intraoral scanners (IOS) are also faster and more cost-efficient for users, while being less intrusive and uncomfortable for patients. Traditional impression taking methods may be tried and true, but the reliability and performance intraoral scanning for digital impressions has increased dramatically in recent years. Switching to intraoral scanning has never been easier or more reliable than it is today. The Heron IOS is a fast and easy to use system that provides reliable and accurate results every day – take advantage of this technology in your own practice today.

BOOKreview

Breath: The New Science of a Lost Art Review by Steve Carstensen, DDS

“N

o matter what you eat, how much you exercise, how skinny or young or strong you are, none of it matters if you’re not breathing properly.”

So begins Breath, by medical journalist James Nestor. Most people are unaware of how breathing is woven throughout our everyday lives. Anyone who breathes benefits from reading this entertaining exploration of the power of the breath and the impact poor breathing can have on the whole body. Breath will bring this seemingly automatic respiratory function to life – no one can finish this engaging story and breathe the same way as before. While researching breath-hold diving for another book, Nestor became curious about his own respiration, noting repeated challenges of pneumonia and chronic nasal stuffiness and wondering if there was a better way to health. Reaching out to experts across medicine, dentistry, and mindfulness practice, the curious author put himself in the subject’s role through a breathing experiment at Stanford University; an experiment he labels ‘heinous.’ Seeking an understanding of his body’s response to the 10-day nasal breathing restriction led to discovery of expert opinions about anthropology, physiology and unexpected impacts of breathing patterns on the structure and function of the body. Extensive notes and exhaustive research underpin the real-world presentations of Nestor’s experience, providing any healthcare provider scientific support for conversations with those in their care. Breath was not written for the clinician, however, but for anyone seeking improved health or simply desiring to understand what happens to them when they intentionally change their breathing pattern. This is an informative, entertaining, practical read. From the first story about unexpected results of a breathing workshop, Nestor leads the reader through discovery of ancient lessons about the breath to today’s experts guiding people to startling improvements. Go with him into the catacombs of Paris, an English

castle, and an hour north of his home in Marin County to explore what is possible today. Readers of Dental Sleep Practice are notably focused on how people breathe through the night, often supporting dysfunctional airways. Many of those treated are in need because of chronic mouth breathing, poor skeletal development, and bad habits that arose during childhood. All of these topics are found in the pages of Breath, connected with experts providing insight from years of research or support from centuries of practice. Providers who want to help their patients engage with their health more fully and to expand therapy beyond the first level will be rewarded when they use knowledge found in Breath or recommend it to those patients interested in a deeper understanding. Beyond the book, James Nestor’s website and blog have opened the world of breathing to thousands of people searching for improved health. Nestor enlists the help of experts in the field to answer questions and posts them for all to see; videos provided by these experts expound on the book’s information and will serve to improve community health in unmeasurable ways. Everyone interested in breathing should go to their local bookstore and purchase Breath right away. Visit the author’s website, MrJamesNestor.com, to sign up for updates, interesting postings, and videos. Our patients’ lives will be better when we apply what we learn. Breathe.

Steve Carstensen, DDS, FAGD, FACD, FICD, D.ABDSM, has treated sleep apnea and snoring in Bellevue, WA since 1988. He is the Consultant to the ADA for sleep related breathing disorders, has trained at UCLA’s Mini-Residency in Sleep, and is a Diplomate of the American Board of Dental Sleep Medicine. He lectures internationally, directs sleep education at Airway Technologies and the Pankey Institute, and is a guest lecturer at Spear Education, University of the Pacific, and Louisiana State Dental Schools, in addition to advising several other sleep-related manufacturers. For the AADSM, he was a Board Member, Secretary-Treasurer and President-Elect. From 2014–2019, he was Editor of Dental Sleep Practice magazine.

DentalSleepPractice.com

COMMUNICATIONS

A Recipe for Success: Have the Right Conversation by Michael Cowen

re there really that many sleep patients who need your help and where are they?

I’ll give you a hint. Yes, they are on your schedule, in your chair, and in your waiting room right now. They were on yesterday’s schedule, too. You did hygiene checks on some of them, one canceled, and you prepped a Bruxzir on #30 for another. The path to treating more patients in your practice starts with screening, and there is a recipe to have a successful screening protocol. It contains three key ingredients that will aid you in clearly and quickly identifying these patients. The first ingredient lies in the patient’s health history. If it includes any of airway disorders, you Do you know the indication should initiate a conversation about difference between airway health. A short list would inany cardiac condition (including signs (physical evidence clude: but not limited to hypertension), histoobserved in an exam) or ry of stroke, diabetes, obesity, chronic or mood disorders. symptoms (subjective headaches, Do you know the difference beinformation shared by tween signs (physical evidence obin an exam) or symptoms the patient)? served (subjective information shared by the patient)? They aren’t the same, but both are useful here. Signs are the second ingredient in the recipe. Signs of an airway disorder are easily distinguishable and include: Mallampati score of 3 or more, bruxism, scalloped tongue, and acid reflux. When you observe these signs, it’s an indicator you should have a conversation about airway health. The third ingredient is patient symptoms. These can include snoring, morning headaches, chronic fatigue, difficulty concentrat-

54 DSP | Spring 2021

ing, excessive napping, and dependence on stimulants such as coffee, soda, energy drinks or medications. If your patient presents with any of these symptoms, have a conversation about airway health with them. That brings us to the real problem, right? The conversation. The crucial conversation. Your last patient was 15 minutes late. There’s a hygiene check in Op 2 and an emergency patient in Op 3. You’re already 20 minutes behind, and there’s no end in sight. How in the world are you supposed to have this conversation with the patient who screened positive for an airway disorder? You don’t do it. No one does. And that is why it is so hard to “find” these patients. Because you’re not talking to them. The following is a template taking all these variables into consideration. It’s mindful of the dynamic environment of your practice, and this template works. Try it 3 times. Ruth is a 62 y/o female and longtime patient of your practice. She’s in overall good health with a clean health history (Ingredient #1) which has no chronic diseases managed by any medication whatsoever. Her intraoral signs (Ingredient #2) include a Mallampati score of 3, significant wear facets, and a scalloped tongue. But Ruth’s “real” pain points are hidden in her symptoms (Ingredient #3) which include snoring, frequent morning headaches and daytime fatigue, specifically when she picks up her grandson from school every day at 3 p.m. At this point, the moment for your crucial conversation comes into focus. Ruth and

COMMUNICATIONS your schedule will be overwhelmed if you speak with her in detail about everything you just found. You’re already 20 minutes behind, remember? You must make a memorable impact quick. So, you pick the top 3 things you’ve identified that will connect with Ruth and motivate her to take action. Specifically, you want Ruth to get a sleep test that will be interpreted by a board-certified sleep physician who will clearly identify whether or not Ruth has a condition (obstructive sleep apnea) which you are capable of treating. What if your conversation with Ruth sounded like this? You enter the Op and your hygienist gives you the scoop about Ruth. Then you ask the RDH a simple question, “Is there anything else?” After a brief pause, your hygienist replies, “Yes. Ruth has a Mallampati score of 3 and signs consistent with abfractions on 18/19 and wear facets on 8/9. She frequently has morning headaches and fatigue in the afternoon when she drives to pick up her grandson from school.” You look at Ruth in the eyes with compassion and say, “That sounds hard. How often do you feel tired when you are driving?” “Almost every day. And it terrifies me to think I could hurt my precious grandson. He is my life”, Ruth shares emotionally. “OK, let me take a look,” you respond. As you do a quick intraoral exam, you confirm exactly what your hygienist referenced. Now it’s time for action. “Ruth, I’m so glad you told us about this today. I am concerned that you might have an airway issue that is attacking your sleep, which would explain what I’m seeing in your mouth as well as your morning headaches and sleepiness in the afternoon.” You continue, “I would love for you to wake up pain-free and with all the energy you need for your day so you can spoil Tommy even more. Would you like to see if we can help you get there?” How do you think Ruth responds? 98% of the time Ruth is getting a sleep test. With gratitude for her motivation to move forward, you define the next step. “I’m glad to hear that. Right now, we need to get more information. So, this is where I call on a physician who is a sleep expert to give us more insight.”

Let’s break down the 3 components of what I call “hero positioning” that just happened in this short conversation. 1. Disassociate the person from the problem – We have to help Ruth understand that she is not the problem. But she does have a problem that can be overcome. 2. Connect their emotional pain points – Connect Ruth back to her own value system. Her grandson is at the top of the list and her fear of harming him almost stirs her to tears. And no one wants to be in physical pain with those morning headaches. 3. Identify a positive alternate outcome – Ruth already knows what it is Most general dentists like to wake up in pain and feel screen less than exhausted every day. Painting the picture of what her life could be like if she overcame this challenge is a critical, motivating factor for her journey. These psychological underpinnings of their patients for OSA. may not be overtly stated in each dialogue with your patients. But never underestimate their value. When you connect your patient’s value system and emotional pain points, you are in a position to empower them to take action. As you can see, the conversation about airway health is not a difficult one. Nor does it require much time. But like any good recipe, it takes the right ingredients and some practice to get it right. Keep talking. Be confident. Guide your patients to a better life. You’ll taste the results soon.

70%

Michael Cowen, CEO and Founder of Awaken2Sleep, started his journey in sleep medicine in 2003 performing in-lab sleep studies as a classically-trained pediatric sleep technician at Loma Linda Children’s Hospital in Southern California. After recognizing his calling to passionately assist others to help their own patients, Mr. Cowen went on to become an expert in the Business of Sleep Medicine, building and developing a network of sleep centers/ DME companies across the United States. In 2015, seeing an opportunity to bring testing and awareness to the life-threatening condition that almost took his daughter’s life, he founded Awaken2Sleep, a company whose vision is to empower dental providers and their teams to treat patients with sleep apnea.

DentalSleepPractice.com

SEEKandSLEEP

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For the solution, visit www.dentalsleeppractice.com.

56 DSP | Spring 2021

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