Dental Sleep Practice - Summer 2015

THE MAZE RUNNER

By Dr. Erin E. Elliott

THE ILLUSION OF HEALTH

By Mack Newton

GETTING CONNECTED

By Robert R. Rogers, DMD, ABDSM

MAKING A MONUMENTAL DIFFERENCE IN SLEEP APNEA

SUMMER 2015 PLUS

EENY MEENY MINY MOE

Selecting an Appropriate Appliance Supporting Dentists Through PRACTICAL Sleep Apnea Education

By David B. Schwarts, DDS, D.ABDSM

Pre-treatment airway volume

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INTRODUCTION

It’s Practically Flown By

W

here do you go to learn something new? Anyone who treats sleep patients gets basic-to-advanced education; the bravest of them dive in and apply their knowledge to improve community health. Many others think about it and maybe do a few appliances until something gets in the way. The variety of those barriers is legion.

This issue of Dental Sleep Practice celebrates the beginning of our second year in print. The focus continues: to provide practical education to the dentists and dental teams treating patients every day. This issue, timed for the American Academy of Dental Sleep Medicine annual conference, is about “How to Do It.” What keeps you from doing more appliance therapy? I doubt it is the skills required to create and fit an oral appliance – be it nylon or acrylic, the device part is not the big challenge.

I think the first step in any new endeavor is to Start With Why, to quote Simon Sinek, and figure out, along with your team, what service you want to provide. If that step has been taken, and you are clear about what is your preferred future, yet progress is slow, it’s time to ask the folks around you what’s in the way.

Your team may tell you about troubles they have communicating among each other, with patients, with other medical professionals. Each person has a role to play and specific skills to employ. Once they understand what is necessary, and have the resources they need, most dental professionals will do their very best to help achieve clearly defined goals. Finding your team falling short of desired outcomes is more often the

result of poorly defined expectations rather than poor effort.

This issue is full of essays to help.

You may recognize your office in many of them – if you are wondering how to introduce sleep to your practice, or how to get out there in your health care community, there are stories about how others have done that. Medical billing, how to choose Steve Carstensen, DDS which appliance, who does what in Diplomate, American Board of the office, it’s all here. Are you curi- Dental Sleep Medicine ous about how the AADSM got started? Why you should join? Is there research to back up your clinical choices? Wouldn’t it be great if someone on your team reads one of these articles and comes to the next staff meeting with ideas for how to improve your service or systems?

Learning is achieved by doing, and while The first step is sometimes you just need to know the steps, Start with Why the best learning comes when you see examples of success, think it over, discuss it with your team, make your own choices, and debrief the results. Use these essays to recognize your situation; find a path for success and pay attention to how it works out for you.

You will gain the wisdom that allows you to address the unique qualities found in each of our patients. Rewards are sure to follow.

That’s practical education.

to

Do you like what you are reading in DSP? Does it make you think of ideas you have that work and you would like to write about? I would be happy to consider essays from any reader! Don’t be shy – we’ll help any inexperienced writer polish their ideas and spread the wisdom of Practical Sleep Education.

DentalSleepPractice.com

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CONTENTS

8

Cover Story

Making a Monumental Difference: Sports Stars Team Up to Spread Sleep Awareness Retired sports stars and a passionate industry professional are working to improve community health.

22

Getting Started

Starting a Dental Sleep Medicine Practice

by William E. Williams, DDS One general dentist’s journey to add sleep medicine to his practice.

38

32

Orthodontist’s Perspective

Treating sleep disorders with oral appliances

by Dr. Ronald Perkins Based on his own experience, Dr. Perkins opened his thinking to how to grow airways and offers tips he’s found useful in his orthodontic practice.

PAP Info

CPAP 101: The Dark Side of the Moon

by Rob Suter Every sleep dentist needs to know about PAP therapy; here’s a primer.

2 DSP | Summer 2015

56

Choosing Appliances

Eeny Meeny Miny Moe: Selecting an Appropriate Appliance for Your Patients

by David B Schwartz, DDS, DABDSM You have unique patients and dozens of appliance choices.

How do you make the match?

Legal Ledger

69

Morning Repositioning: Is This Therapy the Standard of Care?

by Ken Berley, DDS, JD, DABDSM Getting the bite back is a critical part of your therapy.

Discover the Narval difference Known for innovation and excellence in sleep-disordered breathing for more than 25 years, ResMed has revolutionized oral appliance therapy for the treatment of obstructive sleep apnea (OSA). Discover how you can deliver a great fit for each patient with Narval CC’s advanced CAD/CAM precision technology, the unrivaled alternative to thermaform and acrylic.

Visit ResMed.com/Discover to register for a FREE webinar and learn why Narval CC is the right choice for your office and patients.

CONTENTS

6 Bigger Picture

46 Marketing

by Edward Grandi This is a society problem. You can be part of the solution.

by Rod Willey, DDS, DACSDD Getting the word out to your community allows you to impact health outside your practice.

Why Treating Sleep Apnea Matters – The Larger Picture

14 Meaningful Conversations Holding a Mirror To Your Patients: Using the Lamberg Questionnaire

by Steven Lamberg DDS, DABDSM Engage your patients’ health status at a deeper level.

16 Nutrition

The Illusion of Health

by Mack Newton A no-nonsense approach to improving health, to achieve the very best life, and getting lean.

20 Airway Classification

The Obvious Conversation

by Kevin Kwiecien, DMD, MS Mystified by what’s beyond the teeth?

Dr. Kwiecien makes it easy to teach your team important landmarks.

24 Case Report

The MicrO2™ Sleep Device

by Jerry Hu, DDS, David Kuhns, PhD, Sung Kim, BS, Len Liptak, MBA, Laura Sheppard, CDT A new concept for mandibular repositioning shows great promise.

Keys to Successful Marketing in Dental Sleep Medicine

48 Start-up

David Gergen on Koala Sleep Franchises Marketing and Expansion

What makes a successful practice from a lab professional’s perspective?

5o Practice Management

How I Transitioned to a Dental Sleep Medicine Practice

by Mayoor Patel, DDS, MS You may be excited to treat only sleep patients – follow this story.

52 Future Education

The Maze Runner: Next Steps in Navigating the World of Dental Sleep Medicine

by Dr. Erin E. Elliott After basic education, where can you learn to master sleep therapy?

0 Team Focus 6 Dental Sleep Team Trade Secrets

by Glennine Varga, AAS, RDA, CTA We all have our roles to play in our offices. Which one are you?

28 Jaw Position

2 Combination Therapy 6 OASYS Oral/Nasal Airway System:

by Robert C. Williams, DDS, FAGD We choose the starting point for OAT, but where?

More than moving the jaw

Where Do We Start?

42 Billing Systems

What Sets a Successful DSM Practice Apart?

Panel Discussion with Rose Nierman, Randy Curran, and Courtney Snow Getting paid is critical, but it can be disruptive to your team. Rose weighs in on one solution.

44 Association Benefits Getting Connected

by Robert R. Rogers, DMD, DABDSM Being part of the larger community of dentists treating sleep breathing has many advantages. Dr. Rogers started it all.

4 DSP | Summer 2015

by Dr. Mark Abramson You can open the nasal airway and move the tongue forward at the same time.

5 Product Spotlight 6 The Airhead

Practical Tips 66 Enhancing Retention of a

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

General Manager | Adrienne Good Email: agood@medmarkaz.com National Account Manager | Michelle Manning Email: michelle@medmarkaz.com Creative Director/Production Manager Amanda Culver Email: amanda@medmarkaz.com Front Office Manager | Theresa Jones Email: tjones@medmarkaz.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.DentalSleepPractice.com

3-D Printed Nylon Sleep Apnea Appliance

Subscription Rates 1 year (4 issues) 3 years (12 issues)

72 Sleep Humor

©MedMark, LLC 2015. 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.

by John Viviano, DDS, DABDSM Here’s a modification to one popular device that solves a common clinical problem.

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BIGGERpicture

Why Treating Sleep Apnea Matters –

The Larger Picture

by Edward Grandi

U

ntreated obstructive sleep apnea (OSA) affects not only the quality of life for the individual suffering with the condition, but the quantity of life as well. There is significant amount of medical research now, and more each year, that demonstrates the serious consequences of sleep deprivation / sleep fragmentation / chronic intermittent hypoxia (all of which accompanies OSA) to the person not successfully managing this condition.

It is well documented that multiple bodily systems are damaged by untreated OSA – cardiovascular, endocrine, and vascular, as well as impaired neurocognitive functioning.

This damage can contribute to a number of serious medical conditions; many of these are life threatening / life shortening.

Beyond the individual whose life is shortened and made miserable, there are others similarly affected either directly or indirectly due failure to address OSA effectively. This brief essay seeks to illuminate the public

6 DSP | Summer 2015

health urgency of treating sleep apnea due to the impact spreading beyond just the individual. I conclude with a plea to members of the dental community to intervene.

The harm from OSA extends to the bed partner, if there still is one. Snoring, which frequently precedes the pauses in breathing can disrupt the sleep of the bed partner, as can the gasping and startling that can accompany the arousal that occurs when breathing restarts. It is as though the bed partner has OSA as well with all the attendant conse-

BIGGERpicture

quences – daytime sleepiness, weight gain, and irritability, all from fragmented, poor quality sleep. It would be interesting to see how the divorce rate correlates with the incidence of untreated sleep apnea among previously married couples.

The negative effects on the direct and indirect sufferers can spill over onto the children and other family members. Poor sleep impairs judgment and provokes short tempers; family members suffer. The injury to them may be less apparent but is no less serious – the psychological harm can have consequences into later life.

Excessive daytime sleepiness (EDS), one of the better known sequela of OSA, can have dramatic consequences outside the home as well. The media is full of accounts of drivers, commercial or private passenger, who fall asleep while driving or who are operating a vehicle while drowsy causing serious auto or truck accidents resulting in injury, death and property damage.

The workplace is also not immune from the negative impact of untreated OSA. The cost to employers can be direct; health insurance costs increase to manage chronic diseases like high blood pressure and diabetes. EDS can also result in workplace accidents and errors in judgment that result in financial losses.

The effects of this condition, not properly managed, extend beyond the home and the workplace. The larger community suffers from the additional expense of managing

chronic conditions like heart disease, diabetes and depression through higher health care utilization which in turn results in higher healthcare costs.

A number of years ago, I described this as the ripple effect of OSA. Where the poor health of one sufferer spreads out like the ripples a stone thrown in the middle of a pond, extending further and further out, negatively impacting many people. If one considers how many people who remain undiagnosed with OSA – the numbers are in the tens of millions of adults – the turbulence in the pond is staggering.

Dentists, whether they are actively engaged in sleep medicine or not, have a unique opportunity to help settle the waters by using the semi-annual preventive care visit to educate patients about their risks of sleep apnea. Evidence of mouth breathing or inflammation of the upper airway could lead to several simple questions about sleep quality. Positive findings trigger a referral to a qualified sleep medicine physician for further evaluation.

Oral appliance therapy administered by a dentist qualified in dental sleep medicine is recognized now as a first-line therapy. The number of dentists qualified to provide this intervention and ongoing care is increasing year by year. My hope is that those reading this opinion piece will do what they can to address what unfortunately is seen as a “sleeping” epidemic.

It is as though the bed partner has OSA as well, with all the same problems!

Edward Grandi served as Executive Director of the American Sleep Apnea Association from 2004 until 2014. His background in sales and marketing helped transformed the association, making it more dynamic and responsive to the needs of its various constituencies. He was frequently quoted in regional and national media on the prevalence of sleep apnea and diagnostic and treatment options available to address this chronic disease. He was a nationally and internationally invited speaker in the field of sleep medicine to patient and professional groups.

DentalSleepPractice.com

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COVERstory

8 DSP | Summer 2015

COVERstory

SPORT STARS LIKE ROY GREEN, CHARLES BARKLEY, AND DEREK KENNARD HAVE TEAMED UP WITH DAVID GERGEN TO FOCUS AWARENESS OF SLEEP APNEA AMONG HEALTH PROFESSIONALS AND PATIENTS. THESE LEGENDS SHARE THE SAME COMMITMENT TO HELPING PEOPLE WHO SUFFER FROM SLEEP APNEA AS MEDICAL PROFESSIONALS WHO ACTUALLY PROVIDE THE CARE. IT IS OFTEN OVERLOOKED THAT, IN SPITE OF THE FAME AND FORTUNE OF A PROFESSIONAL SPORTS CAREER, THESE RETIRED STARS ARE MEMBERS OF YOUR COMMUNITY AND WANT TO CONTRIBUTE TO YOUR OVERALL HEALTH AWARENESS. aving a passion for treating sleep apnea in your practice is like being a world-class golfer holding your favorite club. You’re ready to hit that perfect shot – but despite all you know, all your practice and preparation, you still need a ball to hit and a target to aim at.

You are ready to treat sleep patients, and you’ve gotten your team systems in place. You have the knowledge – you need patients (the target) and oral appliances (the ball, in this analogy) to be able to make the difference in health that’s driven you so far.

This story is about the oral appliances, and how critical support from our industry partners makes it possible to provide therapy. Beyond creating the Sleep Herbst, EMA, TAPs, or any of the other 100 or so devices, though, have you thought you could use the passion evident in the dedicated professionals who support us? Can you see a connection between what they do and maybe the patient in front of you that you are trying to convince to get diagnosed?

It’s fair to say there are few in the profession with more passion for connecting people with treatment than David Gergen. By 2008 he had spent over 30 years improving jaw and tooth

function by making orthodontic appliances. By servicing and training under a number of the field’s leading providers, including Dr. Harold Gelb, Dr. Robert Ricketts, Dr. A. Paul Serrano and Dr. Edward Spiegel, Gergen had raised the standard of orthodontic appliance. His innovations brought him Top Dental Lab Technician in the Country honors. It wasn’t enough for someone driven to excel; he looked around and realized that he had friends and family with obstructive sleep apnea who were completely untreated.

They had been diagnosed and given CPAP, with many unable to comply with the therapy. They were risking all of the negative impact of not breathing well while asleep. Always a sports fan, Gergen knew the story of Reggie White of the Philadelphia Eagles who passed in 2004 due to complications from untreated sleep apnea. Reggie White and Roy Green were team mates on the Philadelphia Eagles. The biggest star in the city at that time had just been traded from Philadelphia 76ers to the Phoenix Suns, Charles Barkley. All three of these superstars knew each other very well. David, knowing he needed to be part of a solution so his friends would not suffer the same fate, put these two related issues together and changed the course of his life’s work.

It was while working for the greatest dentists in the country Gergen learned DentalSleepPractice.com

9

COVERstory the technique of supporting the airway by using an acrylic appliance to hold the jaw slightly forward while the patient is asleep.

The device is small, easy to wear, and can be very effective in opening the airway. It rapidly became obvious that this was a therapy that needed a little promotion – something that is successful, easy to make and for patients to use. Patients loved it and tended to wear them all night, every night. Obstacles to overcome included medical practitioners who do not have a good understanding of the workings of the jaws and the effect that minor repositioning can have on the upper airway. Dentists also had a great deal to learn about the upper airway and their role in treating the disease diagnosed by the sleep docs.

While looking for a way to make an impact, longstanding friendships with current and former sports stars resulted in conversations about their sleep breathing problems.

Several players fit the same profile found across the country in countless dental offices – people at risk for sleep breathing problems, diagnosed but given only one solution. What was required was a high-quality solution.

Professional athletes are used to standards set at the highest levels – this prompted Gergen’s Orthodontic Lab, already a top tier appliance creator, to carry on at that level while embracing sleep apnea device fabrication. The Sleep Department was added in 2009 and in 2012 was one of only two labs in the country authorized to make Medicare-approved devices. Over 100,000 custom appliances now serve sports stars, including legendary NBA and NFL athletes, and vastly more everyday people, helping them to better health.

How can you use this in your practice?

Every dentist and other medical professional struggles to help their patients see their risk factors for disease – we can see it but they don’t. We know that men carry a greater risk of OSA, they tend not to see the doctor, and they deny signs and symptoms clearly observed by others. (Stereotypes come from somewhere!) How can the dentist connect with these guys?

Sports! If your patients won’t listen to their spouse, or you, maybe they will listen to NFL Superstar Roy Green or NBA Hall of Famer Charles Barkley! Charles and Roy are both extremely excited to continue educating and assist in the fight against sleep apnea.

10 DSP | Summer 2015

1. Herbst sleep appliance 2. Marcus Allen, Mack Newton and Roy Green 3. Roy Green, Executive Director NFLPA’s Professional Athletes Foundation Andre Collins and David Gergen

Roy Green says, “It all begins with eight simple questions, now, that’s not too painful, is it?”

1. Do you snore loudly?

2. Do you often feel tired, fatigued, or sleepy during daytime 3. Has anyone observed you stop breathing during your sleep?

4. Do you have or are you being treated for high blood pressure?

5. Are you over weight?

6. Age over 50?

7. Do you have a large neck?

8. Gender male?

“If you say yes to 3 or more questions go get a sleep test”. Gergen and Green spent a significant amount of their own time and money traveling the country working with veterans groups and football fans before they realized just how impacted the retired professional football community is by sleep apnea and related co morbidities including diabetes, obesity, heart disease and stroke. Charles Barkley is one of the most influential and outspoken celebrities in the country, and is very enthusiastic to add his charisma to the campaign. Charles is, and has always been, very concerned about the health of all current and former athletes. 2015 will prove to be a turning point in the identification and treatment of obstructive sleep apnea based on the efforts of this trio they are committed to raise awareness of this disease.

Look for publicity from Gergen’s Orthodontic Lab and the Pro Player Health Alliance, the partnership that Gergen and Green created, to help you connect with your patients. Getting celebrities involved with health care, making a positive statement, counters the more often reported bad behavior and scandal. It might even get the attention of that high risk gentleman in your chair!

Some retired athletes are more than just celebrities: Dr. Archie Roberts was an NFL quarterback and went on to become a cardiologist and Founder of the Living Heart Foundation. Its HOPE (Heart, Obesity, Prevention, Education) Program is a comprehensive obesity, pulmonology, sleep, dentistry

4. Dave Krieg, David Gergen and Warren Moon 5. Mike Haynes, David Gergen and Dr. Archie Roberts at the NFLPA office 6. Nesby Glasgow, Warren Moon, David Gergen, Mark Walczak, and Dave Krieg

“I cannot say enough positive things about my friend Roy Green…he has pulled me through some major life struggles, and for this I am grateful. Roy introduced me to Charles, who in my opinion is one of the most caring human beings I’ve ever encountered...there is never a time I have not seen his generous spirit in action.

I am fortunate to call both of these men my friends.”

– David Gergen

12 DSP | Summer 2015

and overall health campaign sponsored by the NFL Player’s Association’s Professional Athletes Foundation, which strives to promote healthy lifestyles among former NFL players. According to a study by the New England Journal of Medicine, up to a third of NFL players suffer from sleep apnea and as many as 60% of NFL linemen may suffer from the disorder.

Former players are not different from your patients in their ability to tolerate PAP therapy or wish for a simpler solution.

Gergen has used his sports connections to position his Sleep Lab as the leading promoter of sleep apnea awareness in the athletic community. Through the “Tackling Sleep Apnea” Campaign, which was launched in 2012, over 200 retired NFL players including Roy Green, Derek Kennard, Eric Dickerson, Tony Dorsett, Mike Haynes and many more legends have received obstructive sleep apnea treatment with a sleep appliance made by Gergen’s Orthodontic Lab while using their position to spread awareness and urge treatment.

Tony Dorsett, a former Heisman Trophy winner and NFL Hall of Famer, had claimed before being diagnosed with obstructive sleep apnea to be “snoring like a freight

train.” Then he received his sleep Herbst custom fitted by Gergen’s Orthodontic Lab. Now that he breathes well while he sleeps he proudly boasts “Superman ain’t got nothin on me.” He gives credit to Pro Player Health Alliance, David Gergen, the LHF HOPE program and Gergen’s Orthodontic Lab for being able to sleep well at night.

To help dentists meet this health challenge, David also has invested in stateof-the-art digital technology including an advanced 3D printer and support for digital impressions. Since 2011, he has also sponsored well-received educational courses with a wide variety of speakers. Since 2013, Gergen has aligned with the American Sleep and Breathing Academy to connect dentists, physicians, respiratory, therapists and sleep technologists in education and collaborative care. The Academy’s vision is to create convenient, affordably priced and highly reviewed classes, uniting both the medical and dental sides of the sleep community. These classes can be taken online or in person.

You may be ready to take a swing at sleep disorders in your practice. Celebrities like famous athletes are spreading the word – getting your patient’s attention, creating ‘targets’ for you to aim your efforts towards. Dedicated professionals like David Gergen are out there stirring things up to raise awareness, all the while making the highest quality oral appliances for you to tee up. Fore!

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All so you can treat more patients.

Springstone Patient FinancingSM, known for offering patient-friendly products and excellent customer service, has joined Lending Club, the world’s largest online credit marketplace, and is now Lending Club Patient Solutions.

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No Interest for 6, 12, 18 or 24 months, after that 22.98% variable APR. Interest will be charged to your account at the standard variable APR of 22.98% (based on the Prime Rate) from the end of the promotional period on the remaining balance if the purchase balance is not paid in full within the promotional period. Minimum monthly payments for this plan during the promotional period will be the greater of: the amount of the purchase divided by the number of months in the promotional period (rounded up to the nearest $1.00); or $5. Required minimum purchase of $499 for the 6-month plan; $999 for the 12-month plan; $1,499 for the 18-month plan; $2,499 for the 24-month plan. Lending Club Patient Solutions credit accounts are offered by Comenity Capital Bank who determines qualifications for credit and promotion eligibility. Minimum Interest Charge is $1.00 per credit plan. Standard variable APR of 22.98%.

2 Rates range from 3.99% to 19.99% APR. Terms available based on amount financed and credit history. All Extended Plan loans made by NBT Bank, N.A. member of FDIC. Please visit lendingclub.com/healthcare for current rate information. © 2015 Lending Club Patient Solutions products and services provided through Springstone Financial LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners. lendingclub.com/providers.

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MEANINGFULconversations

Holding a Mirror To Your Patients: Using the Lamberg Questionnaire

by Steven Lamberg DDS, DABDSM

Y

ou may think you know your patients, but if your attention is focused only on their teeth and gums, you could actually be treating ‘strangers.’ When you start learning how to treat medical problems such as sleep apnea, you take on the need and desire to know more about the whole person!

The Lamberg Questionnaire (LQ) evolved from a closing slide in my 2-day seminar titled “My Wish List”. Naturally I wanted my attendees to take action with the information that had been carefully presented, but a risk assessment tool created from the published data on the prevalence of obstructive sleep apnea (OSA) associated with comorbid medical conditions did not yet exist. Hoping someone “out there” would take on this important project accomplished nothing; so creating one myself was the natural solution.

Following an invitation to do a webinar for Nierman Practice Management, I suggested this project as a topic and they completely embraced it. The work began by compiling odds ratios by medical specialty and the webinar was very successful. Subsequently, the quest was on; I continued to search the literature for all the relationships between sleep disordered breathing (SDB) and any medical conditions and my enthusiasm grew as I realized the vital importance of organizing this information. In discussing this with Steve Carstensen in Minneapolis at the AADSM meeting last June, he suggested I format the

14 DSP | Summer 2015

information into an article, which ultimately was published in the fall edition of Dental Sleep Practice, thereby releasing the Lamberg Questionnaire to the profession.

The reviews on the article were almost all very positive, however several commented that the questionnaire had not been validated and, without that proof of reliability, may not have a legitimate clinical application.

Validation refers to scoring a questionnaire and, based on the results from a known population, the sensitivity and specificity of the instrument can then be calculated. In this case, it would mean how reliably it predicts the risk of having SDB. The process would involve administering it to a substantial number of randomly selected patients, having them tested with PSG or HSAT, and then evaluating how positive and negative predictions compared to ‘reality.’

It is true that the LQ has not been validated, but does it really matter? It is important to appreciate that assessment of risk is not a diagnosis and therefore 100% of “moderate to high” risk patients need to be evaluated with either a polysomnogram (PSG) or a home sleep apnea test (HSAT) regardless.

Although some have suggested that “sleep” should be elevated to the status of a vital sign, it is not recommended to administer a PSG or an HSAT for screening purposes to otherwise healthy patients. If the patient does have medical conditions listed on the LQ it is possible that their risk of SDB is elevated and the

MEANINGFULconversations overnight sleep test could corroborate this.

An additional benefit of the LQ is that if the sleep test revealed normal sleep, the treating physician would be able to eliminate SDB as a cause of the medical condition revealed in the LQ and investigate other possible causes.

The lack of validation of the LQ, although important, does not dismiss the information that may be gleaned about the causal factors of the patient’s medical conditions, even in the absence of SDB. Just asking the questions has value to the patient and practitioner.

The LQ, in my office, is also useful for internal marketing as well as patient education.

It often helps initiate conversations that bring about a deeper understanding of the patient’s medical history, current status, and desires for improved health. Our hygienist is able to use it to stimulate a dialogue about sleep and educate our patients about the relationship between sleep and many common medical conditions that the patient never knew were related. Our dental hygienists are often surprised to discover that some of the patients that seemed highly unlikely candidates for having SDB, are indeed suffering with this condition.

The LQ has been requested and is used by primary care physicians to prompt similar dialogue in their offices. Several offices have asked for replacement pads of the LQ and publicly display them in their waiting rooms.

The LQ is also utilized in medical specialty offices such as pulmonary, otolaryngology, cardiology, rheumatology and more. Specialists are beginning to connect the dots about the relationship of SDB and many of the conditions whose symptoms they are actively treating. In fact, several cardiology offices in our area are now more actively questioning their patients about sleep disorders.

One the most important yet unexpected benefits of the LQ is it’s value as a powerful teaching tool for my dental colleagues, as it summarizes the effects of SDB in a system-by-system approach. Any dentist involved in education can use the LQ to expose students to the enormous impact that SDB can have on the various medical systems in our bodies.

Clinicians are urged to review the patient’s answers with them and determine how the puzzle pieces fit together. If the patient checks off 1 or more items in the Section 1 (standard questions), and then checks additional items in other sections, one might sense that their risk of having SDB is elevated, and a PSG or an HSAT may be warranted. I cannot emphasize strongly enough the rewards I have felt when patients understand and appreciate that I am truly interested in them and supporting their health. Of course, that presumes that their dentist understands and is familiar with the questions being asked!

The LQ has been augmented since the DSP article was published, and the latest version is available at no charge for downloading at www.LambergSeminars.com. Alternatively, the form can be ordered in pads of 50 for less expense than printing it yourself. As more research shines light on the comorbid medical conditions of SDB, the LQ will be updated and posted at this location for your convenience.

If we, as dental professionals, are going to maximize our contributions to community health, we must go beyond excellent gum and tooth care. Use the Lamberg Questionnaire, use a different risk assessment tool, or use whatever instruments you like, but get to know your patients more fully and you will see and make a difference – to them, to your team, and to yourself as a professional.

Dr. Steven Lamberg has been practicing dentistry for over 30 years and has developed a passion for Dental Sleep Medicine over the last 10 years. After attending Washington University in St. Louis, he earned his DDS at NYU College of Dentistry. His pursuit of education led him to the Dawson Center and later to study in Seattle at the Kois Center. Dr. Lamberg went on to become the founder of the Long Island Center for Dental Esthetics and Occlusion, developing and presenting hands on clinical dentistry programs on the latest and most effective methods of cosmetic, reconstructive and implant dentistry. He served as Chief of Staff at the Jewish Home and Hospital in NYC, President of the New York Chapter of the American Academy of Cosmetic Dentistry, Associate Clinical Professor at SUNY Stony Brook Dental School, and presented lectures and clinical courses on occlusion and esthetic dentistry at NYU College of Dentistry.

Dr. Lamberg also created Lamberg Seminars, offering clinical courses in Dental Sleep Medicine for the entire team. He is the inventor of the Lamberg SleepWell Appliance “LSW” which is a patented, FDA cleared intraoral device for the treatment of snoring and OSA. Dr. Lamberg is a Diplomate of the American Board of Dental Sleep Medicine and the Academy of Clinical Sleep Disorders Disciplines. He lives and practices in Northport, New York. For speaking engagements, he can be contacted at 631-261-6014, or SteveLambergDDS@gmail.com.

DentalSleepPractice.com

15

NUTRITION

by Mack Newton

N

o one gets old by surprise. No one. There is a basic confusion among people concerning health today. People believe that their weight alone determines whether they are healthy or not. Your weight only determines one thing…what you weigh. It’s the numbers behind the weight that are really important. The number that indicates your body fat level…it’s the number that indicates how much lean muscle mass you have… and the numbers that tell you how much energy you have. Your weight doesn’t have the answers to any of those questions. So, you can see why I’m continually amazed to hear people say that all they have to do in order to get healthy is to lose a few pounds. That’s ridiculous.

I’m NOT in the weight-loss business, it’s really too insignificant for my experience…I’m in the health business. What a person weighs really isn’t that important to me unless they’re obese or morbidly obese.

In order for people to sleep better, be less irritable, be more optimistic and simply have much more energy, they need more oxygenated blood flowing through their bodies and brains 24 hours a day. The only way that I know of to get that is to build more lean muscle mass and reduce the overall fat mass.

Done properly, through proper eating hab-

16 DSP | Summer 2015

its and exercise, at least 3 times each week, one can use the available fat mass to build lean muscle mass and in the process overall weight will be a casualty.

The proper eating plan I recommend is the 3-2 eating plan I developed over 30 years ago. Originally, I developed the 3-2 for people who are extremely active…exercising between 3-7 times every week. I also developed it for people who really like to eat.

People who like to eat beautiful food…delicious food…fabulous food. The unique thing about the 3-2 is that it is not a diet. It’s an enjoyable eating plan developed out of my need for more energy after I began my professional career of teaching Taekwondo. The amazing by-product of the 3-2 eating plan is weight normalization and lean muscle mass gain. And, because my plan is not a diet… as long as you remember that the 3-2 philosophy and combine it with light to moderate exercise, you can easily satisfy your gourmet tastes and never feel hungry again.

The 3-2 eating plan is easy to remember: There are 3 things you can eat…fresh meat (beef, pork, lamb, poultry and fish that is

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NUTRITION baked, boiled, broiled, sautéed, fried or barbecued), green vegetables and fresh fruit.

There are 2 things you can drink…120 ounces of fresh clean water each day (not carbonated or flavored) and real, fresh fruit juice (hopefully cold-pressed for maximum quality). I do have a short list of “do not eat” things. It’s really just good, common sense. No salt, sugar or white flour. See? It’s really easy.

This means no bread, no crackers, no cake, no muffins, no pasta, creamy dressings, dairy, soda and no alcohol.

I am one of those people I described earlier who loves to eat. I Mack Newton with his wife Natasha and their mean, I really love to eat. It’s one son Nelson. of the reasons I work out so hard and consistently is that it allows me to eat almost anything I want and as much of it I want. I love everything about food. I love the way it looks…I love the way it smells…and I really love the way it tastes. I’ve always felt that food was one of the three great gifts from God to all of us to stimulate our senses, the other two being music and dance. That’s right…to me, food is much more than just nutrition for the body; it’s nutrition Mack Newton training hard his entire life. for your mind and soul.

Food and eating should never have any guilt attached to it. You should always feel good after having a well-prepared, beautiful meal. If you feel guilty after eating, maybe you’re eating for the wrong reasons. It could be that you’re eating to punish yourself for

what you saw as inappropriate behavior in another part of your life. Maybe you were binge eating. Whatever. So, in those cases it’s not the food you need to change, it’s your attitude towards food that needs to change.

Food is never the bad guy…food is our friend.

The most commonly asked question I get about the 3-2 eating plan concerns my recommendation to eat so much meat. I recommend that for each 2 ounces of meat, you need to eat at least 3 ounces of a green vegetable. So, if you’re going to have a 8-ounce steak, you need 12 ounces of a green vegetable like asparagus, spinach or broccoli. So, the most commonly asked question is: “Isn’t eating all that fat bad for you?” No. This is another area of mass confusion. There isn’t a corollary between dietary fat and body fat levels. The fat that makes you fat comes from eating bread, cakes, cookies, gravies and other processed and refined carbohydrates along with elevated consumption of starches and sugars. You probably already know that bread is NOT your friend.

Most of you know that for the last several decades, the government agencies concerned with health care have continually bombarded us with the message to reduce your total fat, saturated fat, and cholesterol in order to reduce your weight and get healthy. The government has been unrelenting with this message over the years, so much so that the terms “healthy” and “lowfat” seem linked somehow, but the rationale for a low-fat diet is based on ideas that are simply incorrect. It amazes me how the government continues to promote this madness of a low-fat diet in the hope that somehow, as if by magic it will somehow…take and

Mack Newton has trained in the Martial Arts for over 52 years and has been the Conditioning Coach for the Oakland A’s and the Dallas Cowboys, developing many new training methods that have been credited with saving and extending the careers of several Major League baseball and NFL football players.

In 1987, Mack had his left hip replaced and used his own rehab methods to regain full usage of his legs and return professional players such as Neil Lomax and Bo Jackson to competition.

In May 1995, Mack was inducted into the World Martial Arts Hall of Fame for his achievements and contributions to the martial art world. In 1997 he published his first book, “A Path to Power, A Master’s Guide to Conquering Crisis,” followed by his second, “The D-Factor”.

He has taught women’s defense classes and been host of TV and radio shows about self-defense, nutrition, and keeping yourself in shape.

Mack is married and lives with his beautiful wife Natasha and their son Nelson in Paradise Valley, Arizona.

18 DSP | Summer 2015

NUTRITION begin to work. They need to face it…it’s bad science.

As I mentioned earlier in this piece, if you combine the unique simplicity of the 3-2 eating plan with a regular light to moderate (depending on your physical goals) exercise program, you will experience amazing gains in very short order. To get you started, I recommend walking as your primary workout.

Walking is one of the most under-rated forms of fitness training available. Start slowly and gradually work yourself up to a 15-minute mile. Whatever you do…don’t begin a new workout regimen by running. Keep in mind you don’t run to get in shape…you get in shape to run. Beginning a new workout program with running on a hard surface makes it highly unlikely that you will be able to continue it very long because chances are very, very high a beginner will injure themselves that way. With issues like a lack of flexibility, strength and of course, proper running technique, failure is almost assured. Walking is far more body friendly…it’s easier to learn and the rewards are immediate and sustainable.

To make your walking program complete, simply add in my free 7-minute workout on my website, www.macknewton.com.

We all must get older, but getting old is a choice. When you don’t make the choice of getting in shape to live, you make the choice of getting old and dying. Every time I sign up a new client, I always ask them; “What are your sleep habits like? Do you sleep through the night? Do you wake up refreshed?” They always look at me with a quizzical face and ask…”Why are you asking me that?” or “How do you know I don’t sleep well?” I can tell just by looking at them. People always underestimate the important of a good night’s sleep. Sleep deprivation is a major issue in America today. Poor productivity, shoddy workmanship, mistakes and just a lack of focus costs American businesses billions of dollars and thousands of lives are lost for the same reasons every year...and, it doesn’t have to happen. Now, good sleep doesn’t come easily. Like so many other valuable things in life, it comes with a price tag. You have to be in shape to sleep well.

You need more blood volume. You need more muscle mass. The amount of sugar and salt most people eat daily keeps the heart beating so fast that’s it’s literally impossible to fall asleep quickly upon going

to bed. And…this is the illusion of health.

Thinking that you are getting in shape just by ‘losing a few pounds’…what a pipe dream!

You can tell how well you’re doing in life at any point by how much ‘peace of mind’ you’re experiencing. It’s like an internal gyroscope. Peace of mind is actually the highest human good. Peace of mind means you live with the absence of anger, fear and guilt.

Wow. The emotional qualities of a winner. The qualities that al- Can you imagine having low you to always be in the present. Peace of mind. Now…can peace of mind without you even imagine having peace getting a good nights’ sleep? of mind without getting a good nights’ sleep? Remember…no one gets old by surprise.

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

AIRWAYclassification

The

S U O OBVI

Conversation...

by Kevin Kwiecien, DMD, MS

I

’m going to go out on a limb and assume that you do some type of a soft tissue evaluation and oral cancer screening in your office. I will also assume that either you or your hygienist routinely documents recession, probing depths and maybe even attachment levels. That’s a lot of soft tissue to look at, but it’s our responsibility and it’s in our patient’s best interest.

So, while you are there……looking at soft tissue……in the oral cavity……like you do every day……as a dentist……and documenting the findings……and discussing them with the patient……like you do…… with every patient……would you be open to looking at another part of the oral cavity?

I mean, with intention?

But before you say yes, you should know that you have to document it just like the rest of the oral cavity. And you might have to talk to the patient about it. Still in?

There is a big space in the back of the mouth in which we are always working. I call it “the air hole.” Like any other hole that is meant to transport fluid or air, the bigger the hole, the greater the volume. So, a small-

20 DSP | Summer 2015

Figure 1

Figure 2

AIRWAYclassification er hole will usually result in less volume. A big hole that decreases in diameter anywhere along the path will result in pressure changes and even a compensatory or reflexive response, sometimes good, sometimes not so good.

We can’t see too far down the air hole, but we can certainly see some structures getting in the way. Tonsils tend to fill up the air hole when they are inflamed or hypertrophied. We can at least note these, grading the right and left separately. One little note in your chart is sufficient.

The soft palate and uvula can also hang down and cover the air hole. There is a well-accepted scoring system for this too, referred to as the Malampatti score, which is used in anesthesia to predict the ease of intubation.

Although I have included the parameters for each scoring system below, if all we did was use the photos above and document the findings, we would be one step closer to helping our patents make healthy decisions.

Remember the other disclaimer? You might then need to have a conversation about your findings with the patient. That’s ok. A simple discussion about an obstruction at the top of a pretty important air hole in their body is a great start. In future articles, I will discuss the implications that the obstruction can have, including snoring, upper airway resistance syndrome, apnea, chronic inflammation, acid reflux, and bruxism.

Modified Mallampati Scoring Class I: Soft palate, uvula, fauces, pillars visible.

Class II: Soft palate, uvula, fauces visible.

Class III: Soft palate, base of uvula visible.

Class IV: Only hard palate visible

II. Grading Scale Figure 3: Grading of palatine tonsils hypertrophy proposed by L. Brodsky

Tonsil 0: Tonsils fit within tonsillar fossa Tonsil 1+: Tonsils <25% of space between pillars Tonsil 2+: Tonsils <50% of space between pillars Tonsil 3+: Tonsils <75% of space between pillars Tonsil 4+: Tonsils >75% of space between pillars

Figure 4

As you know, implementation is always difficult, even with the small changes. So, let’s keep it simple for now and acknowledge that we are the right people to be looking and that we have the opportunity to look there on a regular basis more than any other healthcare profession. Take a look, document, and start a discussion. We would want that for our friends and family, wouldn’t we?

As a member of the Spear resident faculty, Dr. Kwiecien serves as director of Spear Digital Suite, responsible for creating and overseeing digital clinical content. He is also a member of the Spear faculty practice.

Most recently, Dr. Kwiecien served as assistant professor of restorative dentistry at Oregon Health and Sciences University School of Dentistry and director of the university’s faculty dental practice, director of patient admissions, and director of the urgent care clinic, as well as course director of pre-clinical fixed prosthodontics and co-course director of advanced restorative concepts for third- and fourth-year students.

Dr. Kwiecien’s appreciation for and dedication to high-level continuing education began with Dr. Frank Spear more than 13 years ago. He has completed the curriculum at the L.D. Pankey Institute, has belonged for several years to a Tucker Gold Study Club, and many additional accomplishments, including a fellowship in the Academy of General Dentistry. He has been a member of the Spear visiting faculty since its inception.

Dr. Kwiecien is a past-president of the Oregon Academy of General Dentistry. He also maintains memberships in the American Dental Association, Academy of Operative Dentistry, American Academy of Cosmetic Dentistry, American Equilibration Society, American Academy of Sleep Medicine, and the American Academy of Dental Sleep Medicine.

Dr. Kwiecien graduated from Oregon Health and Scinece University School of Dentistry in 1995 and holds a master’s degree in healthcare administration. He has more than 17 years of private practice experience with eight years in academia.

DentalSleepPractice.com

21

GETTINGstarted

Starting a Dental Sleep Medicine Practice

by William E. Williams, DDS

Y

ou may be reading this magazine thinking you want to treat sleep patients but assume that’s only for ‘certain’ dentists with unique practices. Well I’m not one of ‘those’ dentists. My practice is probably similar to yours.

By sharing my story, I hope readers of DSP will realize they too can establish a successful dental sleep practice.

Several years ago I became interested in the role of dentists in the treatment of sleep disordered breathing (SDB). I had many friends who “joked” about snoring and how their spouses (mostly wives) would roll them over or kick them out of bed. As I learned more about the subject, I realized there was a large part of the population not getting the restful sleep they needed. What seemed like a joke at the cocktail party was potentially a serious medical problem. I decided then to learn how to treat SDB patients.

At that time my biggest concern as a dentist was finding the best training for treating SDB patients. I also worried that advancing the mandible with oral appliance therapy (OAT) might create TMJ issues. Even though I felt I had great training in TMJ therapy at the Pankey Institute, I was still a little uncomfortable with the idea. I had concerns as well from a liability perspective since I would be treating a medical problem, not a dental problem. So initially, I decided to pass on getting involved with treating SDB in my

22 DSP | Summer 2015

dental practice. Then in 2010 a good friend of mine, Dr. Richard Hunt, invited me to join him for a Dental Sleep Medicine course in Dallas. I trusted Richard’s judgment on the best courses and speakers for this subject.

I also realized the speakers in Dallas had ties to the Pankey Institute as well. I knew it would be a great opportunity to learn. Unfortunately, when Richard wanted to take the course I was unable to go.

Another opportunity came in 2012. I heard the Pankey Institute was offering a course about dental sleep medicine (DSM).

I knew the Institute would provide exactly what I needed and allay some of my concerns about venturing into the DSM field. So I decided to take the course and was fascinated by the subject. I was fortunate to have several experts in the DSM field teach the course. Afterwards, I was excited to get home and start helping my patients with their SDB problems. Little did I know it would not be the easiest path. I soon realized there were many systems to put in place before I would be ready to treat patients.

First, I needed to get my staff on board.

That was the easy piece of the puzzle. My hygienist was more than willing to learn and immediately started screening our patients for snoring issues and any history of obstructive sleep apnea (OSA). We changed our health history to ask certain questions that would start a dialogue on the subject. We discovered many patients had sleep issues and had been diagnosed with OSA by a sleep physician. Both of my assistants helped organize

GETTINGstarted our sleep exam forms so we would be ready when the SDB patients came to the office. We even sent several patients home with the ApneaLink home sleep test to help educate (not diagnose) them about their sleep concerns.

Next, I decided I needed to find a medical billing partner to help me navigate the medical insurance model about which I knew nothing. This was a tremendous help for my assistant who managed the sleep patients in my practice. I also decided to have a separate charting system for sleep patients to help track their progress. The charting system included not only referrals from others, but also our own dental patients of record.

I even formed a limited liability company named Greenville Dental Sleep Center, LLC to differentiate it from my dental practice, and created a unique domain name for future use.

With my staff engaged and my systems in place, I decided to meet with several sleep physicians in the area. I wanted to share my philosophy of wanting to work with them as a team and not “just make snore guards”. I found many board certified sleep physicians in our area and they welcomed the opportunity to meet and listen to what I had to say.

They were all glad to see a local dentist take a more comprehensive approach to treating sleep patients. They were very helpful and all were happy to hear I would not treat a sleep patient without a diagnosis from a board certified sleep physician. They also liked my plan to send letters during my OAT to keep them informed about the patient’s progress. As I met with the sleep physicians I was surprised to find they represented several medical specialties. The specialties included pulmonology, cardiology, neurology, and psychiatry.

My next plan of action was to see how involved the dental schools in my state were

with DSM. The state of North Carolina has two dental schools. One of them is at the University of North Carolina in Chapel Hill and the other is at East Carolina University in Greenville where my practice is located.

I have spent time at both schools discussing DSM with the faculty and administrators. While teaching at UNC as an adjunct faculty member, I was fortunate to meet Dr. Greg Essick. He was very helpful in offering advice concerning my journey into the dental sleep medicine world. Greg has been very involved in DSM on the national level and lectures to many groups on the subject throughout North Carolina.

Now that my systems are in place, 2015 is the year I plan to put more emphasis on marketing my dental sleep practice online, as well as speaking to other dental offices and civic organizations. I feel this will be a great way to let the public know the role of a dentist in treating what is really a medical concern. I look forward to that challenge and hope it will be a successful venture.

All of us starting sleep practices experience similar challenges, but if I can do it, so can you. If you make this happen, your team will be excited, and your patients and community will be healthier as a result. Take action now to begin treating sleep patients.

Sleep physicians were glad to see a dentist take a comprehensive approach

Dr. Williams earned his undergraduate degree from the University of North Carolina at Chapel Hill in 1981. He received his D.D.S. from the University of North Carolina School of Dentistry in 1985. Dr. Williams is also an alumnus of the L.D. Pankey Institute. He is presently an adjunct faculty member at the University of North Carolina School of Dentistry. He also has served as Assistant Clinical Professor at the East Carolina University School of Medicine.

Dr. Williams has been actively involved in organized dentistry for over thirty years. He is a member of and has held several leadership positions in the North Carolina Dental Society. He is also a fellow in the American College of Dentists, the International College of Dentists, and the Pierre Fauchard Academy. He opened his dental practice in Greenville in 1985.

DentalSleepPractice.com

23

CASEreport

The MicrO2™ Sleep Device

by Jerry Hu, DDS, David Kuhns, PhD, Sung Kim, BS, Len Liptak, MBA, Laura Sheppard, CDT

T

his case report offers a first look at the clinical performance of the MicrO2™ Sleep Apnea Device for the treatment of patients with obstructive sleep apnea. Seven of seven patients diagnosed with OSA were able to be successfully treated with the MicrO2 Sleep Apnea Device.

Background

Obstructive sleep apnea (OSA) is gaining tremendous attention as an acute public health concern. A study by the Institute of Medicine reports that 50 to 70 million Americans suffer from disorders of sleep and wakefulness1. The long-term effects of sleep loss and disorders have been associated with increased risk of hypertension, diabetes, obesity, depression, heart attack and stroke.

One in five car accidents are associated with driver sleepiness. The American Academy of Dental Sleep Medicine notes that over 18 Million Americans have OSA2.

Due to patient compliance issues that limit the effectiveness of the gold standard CPAP therapy3, the mandibular advancement devices (MADs) prescribed by dentists are playing an increasingly important role in the treatment of OSA. Although many studies confirm the effectiveness of MADs, opportunities exist to optimize the design. Along with patient comfort, customization to the patient’s dentition, optimizing mandibular advancement intervals, minimizing the bite opening, and simultaneous advancement of the tongue and mandible are considered some of the key elements for treatment success with mandibular repositioning devices4.

24 DSP | Summer 2015

The New MicrO2 Sleep Device

The new MicrO2 Sleep Device (MicroDental Laboratories, Dublin, CA, Patent Pending) is designed to address many of the known opportunities for optimizing the performance of MADs. The MicrO2 is the first sleep device made from a control cured dental grade poly methyl methacrylate (PMMA) material. This material is less porous, allowing the MicrO2 device to be stronger and more biocompatible than MADs made from traditional, cold cured PMMA material. Because the device’s material is stronger, it can be made smaller and more comfortable than traditional MADs. The enhanced material strength also provides the dentist with more treatment flexibility when it comes to optimizing the vertical bite opening.

MicrO2 is also the first precision milled MAD. Precision milling, as opposed to manual fabrication, offers advantages with respect to accurately mirroring the patient’s dentition, delivering the prescription consistently, and making it easier to replace if a device is lost or damaged. The CAD/CAM process enables a new titration method utilizing precise combinations of upper and lower arches, each with different fin offsets, designed to achieve the doctor’s prescrip-

CASEreport tion. With enhanced retention made possible by precision milling, ball clasps are optional and the MicrO2 device also features a lingualess design that creates more room for the tongue.

Another noteworthy feature is the 90 degree dorsal fin angle. The 90 degree fin angle is designed to hold the jaw forward in the prescribed position even when the mouth opens during sleep.

Case Report: Overview

Though the potential benefits of the MicrO2 may intrigue many dentists who are practicing dental sleep medicine, the compulsory question remains whether or not the device can deliver clinically efficacious treatment outcomes. For the purpose of this case report, efficacy is defined according to three treatment success thresholds that are commonly accepted in the field of dental sleep medicine5. The first success threshold is a post treatment apnea hypopnea index (AHI) score of less than 5. The second is a post treatment AHI score of less than 10. The third is a post treatment AHI score improvement (reduction) of 50% of better, if not exhibiting an AHI score below 10.

This single center case report (Jerry C. Hu, DDS, Soldotna, Alaska) is comprised of seven patients who received a MicrO2 Sleep Device for the treatment of OSA. Each patient was screened for OSA in the practice and completed a home sleep test (Watch-Pat, Itamar Medical, Franklin, MA). Each patient was diagnosed with OSA by a medical doctor who prescribed a MAD as either a supplement or alternative to CPAP. After being fitted with the sleep device, each patient repeated the home sleep test to confirm therapeutic efficacy.

AHI less than 30 but greater than 15, and three were diagnosed with mild OSA, baseline AHI scores of less than 15. The mean percentage of time with an O2 level less than 90% was 15%.

Table 1: Patient Sample Characteristics Age, Years

46

+/- 11

Gender, F / M

2

5

Baseline AHI, Events/hr

29

+/- 28

15%

+/- 20%

% Time O2 < 90%

77 of

patients achieved at least 1 of 3 AHI success goals

The sample was comprised of a mix of newly diagnosed patients, patients who abandoned CPAP therapy for various reasons, and patients who needed to replace a pre-existing MAD.

Case Report: Results

Seven of the seven patients fitted with the MicrO2 Sleep device achieved at least one of the three AHI score success thresholds. Three of the seven patients exhibited post-treatment AHI scores below 5. Five of the seven patients exhibited post-treatment AHI scores below 10. Six of the seven patients experienced an AHI score improvement of greater than 50%.

One of seven patients did not achieve an AHI improvement of > 50%, however this patient did achieve an AHI score below 10.

Case Report: Sample

Although the sample size for this case report was modest (n = 7), the diversity of the participants is noteworthy. The age of the participants ranged from 22 years of age to 55 years of age, with a mean age of 46. Two of the patients were female. Five of the patients were male. The mean baseline AHI Score was 29. Two patients were diagnosed with severe sleep apnea, having baseline AHI scores greater than 30. Two patients presented with moderate OSA,

Chart 1: MicrO2 Sleep Device Pre-Post AHI Score

DentalSleepPractice.com

25

CASEreport Table 2: Comparison of Baseline vs. MicrO2 Therapy Home Sleep Study Results Baseline Name

Age

Gender Study Type

% REM

Patient 1

51

F

Hospital PSG

24%

Patient 2

55

M

Watch-Pat 200

17%

Patient 3

47

M

Watch-Pat 200

Patient 4

25

M

Patient 5

58

Patient 6 Patient 7

Therapy with MicrO2 % O2 <90%

AHI Total

Study Type

Results

% REM

% O2 <90%

AHI Total

% Change % REM

% Change % O2 <90%

% Change AHI Total

AHI < 10

AHI <5

Yes

Yes

-70%

Yes

Yes

-60%

Yes

-26%

Yes

8.90

Watch-Pat 200

29%

0%

2.80

23%

-69%

49%

75.80

Watch-Pat 200

25%

13%

13.20

41%

36%

0%

4.30

Watch-Pat 200

38%

0%

1.30

4%

Watch-Pat 200

25%

37%

24.80

Watch-Pat 200

25%

4%

9.90

0%

F

Watch-Pat 200

37%

0%

11.20

Watch-Pat 200

21%

0%

8.30

-42%

41

M

Watch-Pat 200

18%

11%

61.20

Watch-Pat 200

37%

7%

21.10

104%

-36%

-66%

42

M

Watch-Pat 200

33%

6%

17.60

Watch-Pat 200

15%

0%

3.40

-56%

-100%

-81%

-73%

-89%

-83%

Yes

Yes

Green = Improvement over Baseline

Four of the seven patients experienced an improvement in % REM sleep. One of the seven patients experienced no change. % REM sleep declined for two of the seven patients. However REM sleep time may improve with additional titrations.

Seven of the seven patients were able to achieve a % O2 <90% score that was either zero or a significant improvement relative to the baseline score. Four of the patients achieved a % O2 <90% score of zero.

It is important to note that the post-treatment AHI scores reported in this study reflect the initial mandibular repositioning with the MicrO2 Sleep Device as represented by the initial target bite. Further improvements in AHI scores and REM sleep are possible as the practice continues to optimize the calibration of the airway by titrating the device.

One of the more rewarding results came from a mild OSA case which exhibited AHI, RDI and ODI scores under 2 while wearing the MicrO2 Device. This patient is a shift worker and his spouse reported that his somnolence improved noticeably. Moreover, his REM sleep improved significantly and he felt as if he had slept for a few hours when he actually slept for over 7 hours without interruption. He reported no bite, occlusion, or TMJ-related issues.

Conclusion

Sleep apnea is a growing public health concern that represents an opportunity for dentists to provide important new type of care to their patients. The findings of this single-center case report of seven patients confirm that the new MicrO2 Sleep Device

26 DSP | Summer 2015

is a viable option for treating patients who are diagnosed with obstructive sleep apnea.

Further research is required to evaluate additional potential benefits of this new MAD with respect to patient compliance and mitigation of MAD side effects. The unique design features may yield efficiencies in treatment protocols for the dental office.

For More about Sleep Apnea Diagnosis and Treatment Before practicing dental sleep medicine, the authors encourage dentists to participate in at least one of the numerous continuing education opportunities available on the topic of Sleep Disordered Breathing. The Las Vegas Institute, The American Academy of Dental Sleep Medicine and The Pankey Institute are among the leading providers of continuing education courses on the practice of dental sleep medicine. For more information, contact these institutions and organizations, or contact MicroDental Laboratories.

The authors would like to thank the staff at Dr. Huâ&#x20AC;&#x2122;s practice for managing the data and the patient experience.

References Institute of Medicine. Sleep Disorders and Sleep Deprivation: 1.

An Unmet Public Health Problem. Washington, DC: The National Academies Press; 2006. www.AADSM.org 2.

3.

Kribbs NB, Pacl Al, Kline LR, et al., authors. Objective measurement of patterns of nasal CPAP used by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993; 147:887-95.

[PubMed] 4.

Sutherland K; Vanderveken OM; Tsuda H; Marklund M; Gagnadoux F; Kishida CA; Cistulli PA; on behalf of the ORANGE-Registry. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215-227.

5.

Ferguson KA; Cartwright R; Rogers R et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP 2006;29(2): 244-262.

w

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JAWposition

Where Do We Start?

by Robert C. Williams, DDS, FAGD

Y

ou just took a course in “Treating Sleep Apnea in the Dental Practice” and you are ready to start. Your patient is ready to start. Start where?

You learned all kinds of terms and acronyms (AHI, RDI ...).

You were shown this new device called a George Gauge – which you supposedly set at 60-70% of maximum protrusion, send to the lab, and deliver the appliance to the patient and everyone is happy and breathing better at night. Plus they said you were going to make a boat load of money! Sounds great, right?

Or are there more areas you need to keep in mind? I will attempt to take you through the Who, When, Why and How you take a bite registration for a MAD (Mandibular Advancement Device).

Who can do this? You – as the dentist.

Every MAD works by protruding the mandible. To make a stable appliance, we must determine the best place forward that opens the airway and provides enough posterior clearance to fit the chosen device. We want to find the optimum spot somewhere along that continuum between the most retruded demonstrated position and where they protrude maximally. The Class 3 patient with a very flat protrusive angle may have limited posterior clearance, while a severe Class 2 with a deep overbite will have a very large posterior clearance on opening. Also, if you have a patient with a severely retruded jaw

28 DSP | Summer 2015

and forward head position, you could collapse the airway if you move the jaw too far forward. So there is more to evaluate in a patient then to simply check their protrusive and retrusive relationships and set at 60% or 70% and fit the appliance. You may get away with it most the time, but we, as specialists of the mouth and jaw, can do better.

The When is simple: after the dentist receives a prescription to “Make an Oral Device” from a physician to treat the patient’s OSA. Why? Because we are in a perfect position to evaluate the oral environment. We need to think of ourselves more as physicians of the mouth, not just filling holes in teeth or rebuilding occlusions. We need to include questions in our health history about sleep such as history of PAP use, and screening questions such as STOP BANG, AIRES, and ESS. Our exam should include tongue, palate and pharyngeal structures – is it difficult for you to see the back of their throat? Ask them – have they been told they snore and they say “oh yes, my wife sleeps in the other room”.

Check their jaw relationship (Cl 1, 2, and 3), and for any evidence of occlusal wear from bruxism. We can also do a thorough TMJ evaluation including muscle palpation, joint noise and/or pain. Trust me – your patients may not have experienced such a thorough exam and will be impressed with your con-

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JAWposition

Trust me – your patients have not experienced such a thorough exam

cern not just for their teeth, but their whole being. At this point you can evaluate whether they are a good candidate for a MAD. Now let us get to the How of taking a bite registration for the MAD. I will discuss four options for determining the correct bite registration position. The first two are Airway Metrics and the Andra Gauge. Both depend on the patient’s subjective feedback of snoring sounds, which can help educate the patient about their problem while you are developing a starting point for setting your appliance.

The Airway Metrics, (www.airwaymetrics. com) some say, is practical, simple, repeatable, and accurate in finding the airway target position. It comes with bite forks, handles, and 15 mandibular positioning simulators that give you a broad range of both A/P and vertical positions that can quickly provide a selected bite registration position which is the most comfortable for the patient. The Andra Gauge (http://www.andragauge.com) is a single compact device which adjusts A/P, vertical, and sagittal positions. This will allow you to precisely position the jaw in three dimensions; you use a step-back approach by

decreasing the A/P and opening the vertical so you can find a more compatible position.

Unfortunately, the entire device goes to the lab which increases the cost.

The George Gauge, developed in the 1980’s by Dr. Peter George, an orthodontist practicing in Honolulu, Hawaii. (Side note: he’s a Gold and Silver Olympic medalist in weightlifting between1948 and 1956 while completing dental school.) After attending a course with a local oral surgeon on orthognathic surgery concepts in 1983, the surgeon told Dr. George the story of a patient with severe OSA. Dr. George offered to make an appliance for the patient and dropped the AHI (Apnea-Hypopnea Index) from 79 to 4 as a result. He developed his positioning device to make this process easier; through the years this has been the most used device for bite registration worldwide, distributed through Great Lakes Orthodontics.

The George Gauge and Pro Gauge from Airway Technologies vary slightly. The George Gauge has vertical openings of 2mm and 5mm, while the Pro Gauge has a 4, 6, 9, and 12mm vertical opening choices. The

For more than 35 years, Dr. Robert Williams has provided expert, comprehensive family dental care in the Napa Valley. A lifelong learner, Dr Williams embraces new techniques and technologies that enhance traditional dental methods. He is a founding member of the Napa Valley Evidence-Based Dentistry Group, that brings dental professionals together to review cases and discuss treatments. Dr. Williams believes that evidence-based dentistry enables patients to make informed dental decisions.

Dr. Williams participates in continued sleep disorder education with the most prominent dental sleep medicine specialists in the country. Working with sleep diagnostic centers, ENT specialists and sleep specialist doctors, Dr. Williams creates dental sleep solutions for his patients.

30 DSP | Summer 2015

JAWposition George Gauge adjusts over the lower incisors and is fitted by tightening the lower screw.

Both gauges must fit over the incisal edges of the upper, so sometimes you must adjust the notches to fit if the teeth are severely worn. Then, both gauges work like this: Step 1: Center gauge on lower anterior teeth and make any appropriate adjustments to align the body of the gauge with the plane of occlusion. Step 2: With the patient holding the gauge between the incisors, instruct him/her to slide jaw forward as far as possible. Note the + reading on the millimeter scale. Then ask patient to move jaw back as far as he/ she can. Note the - reading. Repeat 2-3 times to insure consistency. Also notice any deviation in the midline which could affect the outcome. The total distance between maximum + and – is the protrusive range. Step 4: multiply that sum by .7 (70%) and add this number to the minus number (retrusive position). This may or may not be your Therapeutic Position. You will find in some cases that as you increase the vertical you can decrease the protrusive position. Let’s say the patient is not comfortable in the 70% position, and the patient is still making a considerable snoring sound with the George Gauge 5 mm opening, so with the Pro Gauge you could try a 9 mm vertical opening and set the protrusive setting to 50% and patient is making a very slight snoring sound and feels more comfortable. Comfort is key; if the patient is not comfortable, guess what, he won’t wear the appliance. By adding the snoring-sound portion to your treatment routine you will increase your success and comfort for your patient, similar to the Andra and Airway Metric guides. Setting the initial jaw position is currently as much art as science. Since all the MAD are adjustable, so don’t let precise positioning of the starting position be a barrier to getting started.

Pro Gauge vs George Gauge: With cold sterilization being more and more questionable, the ability to heat sterilize instruments becomes more desirable. The George Gauge can’t be heat sterilized while the Pro Gauge, which has more vertical options and an easier-to-read millimeter scale, can.

These features make it a superior choice. The Pro Gauge is also distributed through Great Lakes Orthodontics.

Bite records are the same basically for all devices; mark the center line and record full

occlusal coverage to stabilize the cast mounting. Once the position is set, bite registration material is added to the top and bottom of the bite fork all the way back to the posteriors, then return the marked bite fork to the midline and guide patient into upper groove.

It’s recommended that once a position is obtained that you ask the patient to hold in that position for 2-3 minutes and seek feedback.

If they are not comfortable there, adjust that position less protrusive a bit and try again.

Also patients with a history of TMD may need a less aggressive starting position, but that’s a subject for another essay.

It’s important for your patients to be involved in their therapy; starting where they are comfortable and where they feel their snoring will be quieter leads them to positive thoughts starting out. You and I know that only use of the device and objective testing will truly determine the therapeutic position; that’s why we make our devices adjustable.

But we have to start somewhere!

Comfort is key; if the patient is not comfortable, he won’t wear the appliance.

DentalSleepPractice.com

31

ORTHODONTIST’S perspective

Treating sleep disorders with oral appliances Dr. Ronald Perkins discusses symptoms of sleep disorders and his treatment protocol

Before

After

Before

After

A

n as an orthodontist since the early 1970s, I typically recommended the surgical removal of the enlarged tonsils and adenoids that caused airway blockage in young children. The results of this well-known surgical procedure were immediate: Parents reported that their children were sleeping more restfully, with no snoring and were much easier to wake up in the morning. Within a few months, parents would often say that their children’s schoolwork was improving, along with their health and attitude. After studying the work of Dr. Rolf Frankel and others,1,2,3 who speculated that form followed function and that mouth breathing could affect growth in children, especially regarding long face syndrome and the use of a vertical-pull chin cup therapy, I started using this therapy, along with the removal of tonsils and adenoids, palatal expansion, and mandibular advancement. The pre- and posttreatment photos (Figures 1A-1D and 2A-2D) show the results: healthy children with the reduction and correction of this vertical growth problem.

Firsthand observations of sleep disorder symptoms

As an orthodontist, I was aware of pediatric airway problems and sleep disorders but unaware of my own sleep disorder. I suffered with weight gain, fatigue, and loud snoring.

Fortunately, an alert physician heard me fall asleep in his exam room and recommended that I get a sleep study. Soon after, I encountered an old friend from dental school, Dr. Keith Thornton, inventor of the TAP® (Thornton Adjustable Positioner) appliance at a dental event, and he recognized my sleep disorder too. Within 2 weeks, I was fitted with the oral appliance.

My first night of sleep in the TAP appliance was an epiphany. Normally, I would hit the snooze button at least 2 times before I could get out of bed. But on this night, for the first time in my adult life, I woke up refreshed before the alarm sounded, without fibro-myalgia, numb feet, or acid reflux. I also woke up in the same position and did not “tear up the bed” with my restless sleep. During the day, I was much more energetic. I now recognized a few of the many symptoms of sleep disorders.4,5,6 In the next few months, I lost approximately 40 pounds because I was burning more calories during my sleep, and

32 DSP | Summer 2015

Figures 1A-1D: Patient with long face syndrome, who wore her vertical pull chin cup during first-phase expansion treatment. Note the autorotation closure of the mandible

Before

After

Before

After

Figures 2A-2D: An example of a patient who had first-phase Herbst advancement and expansion and vertical chin cup.

Note how much healthier she looks in the posttreatment photos

ORTHODONTIST’S perspective I felt more like exercising. I began to record the changes after recognizing the symptoms that were improving in my life.

In the meantime, the oral appliance was working well, but my jaw joints were uncomfortable in the morning, so I decided to balance my own appliance to support the joints during sleep, which made me feel even better. Unfortunately, I waited a little too long to balance my appliance because I had developed a Class III occlusion, an all too common side effect of oral appliances.

(This bite change is probably the main reason many dentists are reluctant to treat patients with oral appliances.)

Because my balanced oral appliance was so much more comfortable, I decided to treat all my patients who wore this in the same manner. The results seemed phenomenal, with very few side effects and without creating Class III occlusions. Across the board, I observed a reduction of my patients’ symptoms, as well as a reduction of their headaches. From 30 years’ experience and training in treating temporomandibular joint (TMJ) problems mostly with splints, I became more convinced of the effectiveness of this type of comprehensive treatment. In the past, I was really treating one of the major symptoms of sleep disorders, not the real cause, which is often the nightly clenching and bruxing that adversely affects the jaw joints. Now my goal is to treat the sleep disorder and the TMJ problems at the same time.

This drastic improvement in my life and near-death experience (I was holding my breath for a full minute and having oxygen desaturation of at least 50%), spurred me to start helping others with sleep disorders. I began to recognize their symptoms, which were similar to mine. Along with reading the most current research in sleep medicine, I started to develop a comprehensive list of symptoms

to evaluate and treat patients with potential sleep disorders. Many adult patients were referred to me for TMJ problems, and I began to recognize that many of those patients had symptoms of sleep disorders.7

How do oral sleep appliances work?

Even though there are many different types of appliances, the most commonly used mandibular advancement device (MAD) appliances, such as the TAP, work by slightly advancing the mandible and the tongue to a position forward enough to hold the airway open when the throat muscles relax, thereby preventing airway collapse during deep sleep. My preference from clinical experience is that these appliances should be custom-balanced to support the jaw joints during sleep so as to reduce side effects, such as headaches and bite change. In my practice, the TMJ-balanced TAP appliance and the AM Aligner are used for preventing unwanted bite changes. At the appliance delivery appointment, the AM Aligner (a lowheat ThermAcryl® wafer) is easily formed in the patient’s mouth to his/her normal occlusion or bite.

The patient must use this bite wafer or AM Aligner every morning, Figure 3: AM Aligner. The patient is directed to place the aligner on his/her lower teeth and slowly close usually for 10 to 15 minutes, to into the upper teeth using the ramp created by the slowly and gently reposition the upper incisors. (See the red arrows). All patients jaw back to the normal position who have MAD-type appliances would benefit from using the aligner every day for at least 15 minutes to (Figure 3). return the jaw to its original position

Symptoms of sleep disorders

The symptom list in Table 1 helps to detail the patient’s progress. For example, if the patient is no longer snoring, waking up more refreshed, having no acid reflux, and no morning headaches, this illustrates that the appliance is working. I will also check

Ronald Perkins has a DDS, MSD in Orthodontics from Baylor University College of Dentistry. He is a Diplomate of the American Board of Orthodontics, Fellow of the International College of Dentists, member of the American Association of Orthodontists, and member of the American Academy of Dental Sleep Medicine. A practicing orthodontist in the Dallas/Rockwall area, Dr. Perkins treats patients in many modalities, including Invisalign®, braces, and early treatment to prevent sleep apnea. He improved the design of a sleep apnea/snoring appliance to support the TMJ, a modification that has been more than 96% successful. His extensive experience in early treatment (ages 5-10), such as jaw development, expansion, and airway improvement, reduces sleep disorders in children, and prevents future sleep problems and the need for surgery in adults. He is passionate about recognizing, treating, and teaching others to be more aware of sleep disorders in young children and adults.

DentalSleepPractice.com

33

ORTHODONTIST’S perspective Table 1: Symptom List Name:_______________________________ Delivery Date:_____ Sleep Position:_______ Observer:_____________________________ Follow-up Appointments Unrefreshed Snoring Stop Breathing Tiredness — Tired Eyes Restless Sleep Acid Reflux/Indigestion Fibromyalgia Backache Headaches High Blood Pressure Depression Wake up out of breath Jump when going to sleep Carpal Tunnel Syndrome Heart Problems Weight Gain Night Sweats No Dreams Clincher/Grinder TMD Syndrome

Table 1: Each patient is interviewed using this list to start the diagnostic process, which is then followed by the oral exam.

This list will be used at every treatment visit to evaluate each patient’s progress

for any joint symptoms and adjust the appliance as necessary.

Oral and facial symptoms, such as dark circles or bags under the patients’ eyes, also signal sleep disorders. An interview using the in-depth initial symptom list (Table 1) usually reveals many more symptoms.

Each patient is unique with his/her own particular set of symptoms. (I highly recommend my patients read an outstanding book called Sleep Interrupted by Steven Y. Park, MD, to help them understand their symptoms.) From my experience, many of the adult patients I interview are able to trace these sleep problems to their childhood.

The August 2012 edition of Pediatrics®, the official journal of the American Academy of Pediatrics, reported current clinical guidelines regarding childhood sleep disorders.

In my opinion, orthodontists could play a very important role, in collaboration with pediatricians and sleep physicians in helping young children with these problems using early orthopedic treatment.

Children can have slightly different symptoms than adults (Tables 2 and 3).

Snoring in a child is a possible sign of airway obstruction. Consider these questions: Is the child a restless sleeper? Is the child often tired and/or cranky? Dark circles under a child’s eyes, or “allergic shiners,” may be a sign of sleep deprivation, just as in adults. Large tonsils, retrusive jaws, narrow or constricted dental arches, bad dreams, and bed-wetting may all point to sleep disorders as well.

Table 2: Survey of 10 Lifesaving Questions

The oral exam

A simple oral dental exam can begin to show the clinician signs of bruxism, obstruction, and snoring. The oral exam should include checking for extremely heavy bone formation around the teeth, including tori and exostosis in many cases — a sign that patients may have been bruxing or clenching for a long time, perhaps since childhood. Teeth obviously worn from bruxing and numerous crowns in older adults are also apparent signs in many patients. The next step is to look beyond the teeth into the posterior palatal areas and look for inflammation of the soft palate and uvula, possibly due to snoring or obstruction. There can also be inflammation of the oral pharynx due to acid reflux (see Figure 4). The size of the airway — small, medium, or large (Mallampati scores) — is also a determining factor. Tonsils should not be large enough to obstruct the airway. The next step is the palpation of the muscles of mastication and TMJ areas to determine if the patient is clenching regularly or has pain coming from either jaw joint. Pressing orally behind the retromolar area will elicit severe pain in patients whose muscles are tense from bruxing or clenching, and many of these patients will have headaches behind their eyes. Next, using the stethoscope, I listen to the joints and evaluate crepitus and popping. From my clinical experience, patients with medial pops and the history of locking seem more likely to have problems with an oral appliance.

Table 3: Survey of 10 Lifesaving Questions for Your Child

Do you snore?

___ Yes

___ No

Does your child snore?

___ Yes

___ No

Have you or anyone observed you stop breathing or gasp during sleep?

___ Yes

___ No

Does your child wake up tired and unrefreshed?

___ Yes

___ No

Do you wake up tired and unrefreshed?

___ Yes

___ No

Is your child a restless sleeper?

___ Yes

___ No

Do you doze off easily?

___ Yes

___ No

Is your child often tired and cranky?

___ Yes

___ No

Do you ever wake up out of breath, gasping or coughing?

___ Yes

___ No

Does your child have large tonsils?

___ Yes

___ No

Are you a restless sleeper?

___ Yes

___ No

Does your child have a retrusive lower jaw (no chin)?

___ Yes

___ No

Do you ever have indigestion or acid reflux?

___ Yes

___ No

Does your child have constricted dental arches (crowded teeth)?

___ Yes

___ No

Do you have headaches or jaw pain?

___ Yes

___ No

Does your child have dark circles under eyes (tired eyes)?

___ Yes

___ No

Do you have or ever had in the past high blood pressure?

___ Yes

___ No

Does your child wet the bed?

___ Yes

___ No

Do you ever have night sweats?

___ Yes

___ No

Does your child have frequent bad dreams?

___ Yes

___ No

Three (3) or more YES answers to these 10 questions means you should be further evaluated for SDB. Five (5) or six (6) YES answers means there is a very good possibility that you may have SDB.

Three (3) or more YES answers to these 10 questions means your child should be further evaluated for SDB. Five (5) or six (6) YES answers means there is a very good possibility that your child may have SDB.

Table 2: These questions offer a good start in screening adult patients for sleep disorders. As few as three positive responses should indicate the need for further evaluation

Table 3: Ten questions for children should be answered by the parents. As few as three positive responses should indicate the need for further evaluation

34 DSP | Summer 2015

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ORTHODONTIST’S perspective After discussing the exam results with patients (who have obvious symptoms) and the benefits to their health of treating their sleep disorder, I would then request a sleep study, evaluated by a sleep physician, who will then make recommendations for treatment.

Patients can choose between a home study or an overnight study in a clinic. State laws vary from state to state with regard to the dentist’s role in treatment and diagnosis of sleep disorders, so always be aware of your particular state’s practice rules and regulations.

Upper Airway Resistance Syndrome (UARS) is the first level of a continuum of sleep disorders (Figure 5) that starts with UARS and progresses through snoring, on to severe apnea.9,10,13 Many patients who snore or have UARS9,10,13 can be treated with a dental appliance. I see many patients with UARS who are just as miserable and sleep deprived as patients with severe apnea. The patients who have UARS just stop breathing enough

to cause awakening, which disrupts the sleep cycle, causing clenching and bruxing of the teeth. Another typical symptom of patients is forgetting their dreams, or having no dreams or bad dreams. With treatment, many patients start having memorable, vivid dreams — another positive treatment result for many patients, especially young adults and children.

If patients are ready to start, we will take routine diagnostic records (X-rays, photos, and appliance impressions). As a part of these diagnostic records, the standard cephalometric X-ray also allows for a good view of the adenoid tissue in the upper airway, especially in children. My goal is to teach patients to monitor their sleep disorder by understanding their symptoms. I ask adult patients to record both their evening blood pressure and morning blood pressure for at least 3 days and bring that written record to their next appointment. In many cases, the patients with high blood pressure will often see a lowering of their pressure with treatment, especially in the morning. I have seen patients lowering blood pressure 10 points the first night they used their appliance, a good sign that treatment is working.

Another telling symptom is the tendency to jump or jerk when falling asleep. This often can be the first time the patient obstructs or snores, and they are immediately awakened. Patients’ feedback indicates that wearing the appliance promotes more restful sleep with much less insomnia (also a revealing symptom).

Orthopedic/orthodontic treatment for young children needing airway development

Figure 4: This photo of a teenage patient at his retainer delivery is an excellent example of what can be seen beyond the teeth to the back of the throat. Notice inflammation of the soft palate and oral pharynx. This patient is always tired and had multiple symptoms of a sleep disorder

Understanding Sleep-Disordered Breathing Sleep breathing continuum UARS

Snoring

Sleep Apnea

Figure 5: Sleep disorders range from UARS (Upper Airway Resistance Syndrome) to snoring to sleep apnea. Many patients who do not have sleep apnea still can have a severe health problem that could be recognized and treated

36 DSP | Summer 2015

Now, as I look back at the many patients treated with the Herbst mandibular advancement appliance or with palatal expansion, also including mandibular uprighting expansion to enlarge the developing dental arches to create more tongue space, I realize that their improved health resulted from treatment similar to that of sleep disorders. Most children facially appeared so much healthier, and 20 years ago, I did not understand why this was such a common result. Orthopedic changes were creating more tongue space, as well as allowing the tongue to posture forward, just like an oral sleep appliance. I recognize now that advancing the mandible with the Herbst device has helped many young children breathe better at night. The parents have reported the dramatic results

ORTHODONTIST’S perspective similar to those often seen with removal of tonsils and adenoids.

Along with expansion and mandibular advancement, in most of my patients who will cooperate, I use a vertical-pull chin cup not only to modify vertical growth but also to help the growing child use his/her airway.

Parents are very supportive when they understand what these appliances can do for their child’s long-term health. I learned early from several ENTs that if a person does not use his/ her nose, the tissues will expand from this non-use. Therefore, in growing children, why not help them breathe through their nose and develop the upper airway?

Orthodontists could perform a major role in helping to prevent or reduce the incidence of sleep disorders with progressive early treatment by expanding arches and advancing mandibles or maxillas in some cases and increasing the airway. In my practice, the experience of treating patients with sleep disorders has greatly increased the importance of non-extraction treatment to create tongue space, which can best be accomplished when the child is young (7 or 8 years old).

This could be the only time we can truly expand the airway and help the patients sleep better the rest of their lives.

Cases in point

Another important fact to keep in mind when evaluating symptoms is that sleep disorders seem to run in families. In other words, as an orthodontist treating all age groups and families, I have seen a strong correlation of multiple family members having sleep problems.15 Often, the parents would tell me that

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they had the same problems as a child that their offspring was experiencing. For example, an 18-year-old previous patient returned because of a broken retainer; 4 years after I had completed his treatment, I noticed he was very tired, and after questioning him, I found he had numerous symptoms of a sleep disorder. I called his father, who I had treated for a sleep disorder 9 years earlier, to discuss his son’s issue. The father disclosed that the son had been involved in four automobile accidents, and he had fallen asleep while driving. Before I could get him into a sleep appliance, he had another wreck. It is important to be aware of patients who are tired and cranky, yawn a lot, and always look tired during their orthodontic treatment. You might just help save a young teenager’s life.

Recognizing and treating patients with sleep disorders has truly been the most rewarding experience of my life. Being an orthodontist, which I have always loved, involves treating our patients often for 2 years or more to achieve that final result when the appliances are removed and the patient is really happy. When treating adult patients with sleep disorders, I often have patients return to my office in 1 week commenting, “This appliance has changed my life,” and they often have new attitudes. Young mothers will often comment that they now have the energy to keep up with their children. If orthodontists can prevent a few more children from developing ADD, ADHD, and other cognitive problems by getting more oxygen to their developing brains,11,12,13 we can really make a difference and improve the quality of life for many people.

Orthodontists could perform a major role in helping to prevent or reduce the incidence of sleep disorders with progressive early treatment by expanding arches and advancing mandibles or maxillas in some cases and increasing the airway.

Moss ML, Rankow RM. The role of the functional matrix in mandibular growth. Angle Orthod. 1968;38(2):95-103.

Frankel R. The functional matrix and its practical Importance in orthodontics”. Rep Congr Eur Orthod Soc. 1969:207-218.

Harvold EP. The role of function in the etiology and treatment of malocclusion. Am J Orthod. 1968;54(12):883-898.

Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice Parameters for the Treatment of Snoring and Sleep Apnea with Oral Appliances: An Update for 2005 [Report]. The American Academy of Sleep Medicine. SLEEP. 2006;29(2):240-243.

Beninati W, Harris CD; Herold DL; Shepard JW Jr. The effect of snoring and obstructing sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74(10):955-958.

Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, FJ Nieto, GT O’Connor, LL Boland, JE Schwartz, JM Samet. Sleep disordered breathing and cardiovascular disease: cross sectional results of the sleep heart health study. American Journal of Respiratory and Critical Care Medicine. 2001;163(1):19-25.

Colten HR, Altevogt BM, eds. Sleep disorders and sleep deprivation: an unmet public health problem. Washington (DC): National Academies Press (US); 2006. The National Academies Collection: Reports funded by National Institutes of Health.

Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Ward SD, Sheldon SH, Shiffman, RN, Lehmann C, Spruyt K. Diagnosis and management of childhood obstructive apnea syndrome. Pediatrics. 2012;130(3):e714-755.

Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P. A cause of excessive daytime sleepiness: the upper airway resistance syndrome. Chest. 1993;104(3):781-7.

Bao G, Guilleminault C. Upper airway resistance syndrome — one decade later. Curr Opin Pulm Med; 2004;10(6): 461-467.

Huang YS, Guilleminault C, Li HY, Yang CM, Wu YY, Chen NH. AttentionDeficit/Hyperactivity Disorder with Obstructive Sleep Apnea: A Treatment Outcome Study. Sleep Med. 2007;8(1):18-30.

Gottlieb DJ, Vezina RM, Chase C, Lesko SM, Heeren TC, Weese-Mayer DE, Auerbach SH, Corwin MJ. Symtoms of sleep-disordered breathing in 5 year-old children are associated with sleepiness and problem behaviors. Pediatrics. 2003:112(4):870-877.

Park SY. Sleep Interrupted. New York: Jodev Press; 2008.

Gilles L, Cistulli P, Smith M. Sleep Medicine for Dentists: A Practical Overview. Illinois: Quintessence Books; 2009.

Casale M, Pappacena M, Rinaldi V, Bressi F, Baptista P, Salvinelli F. Obstructive Sleep Apnea Syndrome: From Phenotype to Genetic Basis. Curr Genomics. 2009;10(2):119–126.

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CHOOSINGappliances

Eeny Meeny Miny Moe: Selecting an Appropriate Appliance for Your Patients

by David B Schwartz, DDS, D.ABDSM

W

hen it comes to ice cream flavors I like chocolate, my wife likes vanilla, my kids like mint chip, you get the point. We have many choices in everything that we do in life as well as dental sleep medicine and until we have conclusive evidence that one oral appliance works better in our hands than another, we will be left selecting the appliances for our patients based on a variety of factors. One size does not fit all in this appliance-eat-appliance world.

38 DSP | Summer 2015

CHOOSINGappliances We might select a device based on the preferred choice that our friends use, one that was advertised in the latest periodical, or one which was featured in a weekend course on dental sleep medicine. Our choice quite possibly could be based on whether the patient will be reimbursed an adequate amount from their insurance in order to appropriately reimburse us. Those of us who deal with Medicare know all too well that the appropriate appliance may not be the ideal appliance for our Medicare Demographic or conversely that the Medicare approved appliances are not best for our patients. Should profit be a consideration? Should we make all our patients the least expensive appliance to maximize our gains? How do we make decision based on individual patients and their needs?

Each feature unique to a device is not only a selling point but also the industryâ&#x20AC;&#x2122;s attempt to offer enhancements that make it more appropriate for your patient and more attractive to us. Along with these enhancements comes our individual preference for design and specific comfort features. The laboratory may include add-on values such as digital storage of the models, free shipping, including a morning repositioner with the case, and lowering the cost to influence the economics of what we do. I hope to share with the reader the process I use in selecting an oral appliance to treat my patients.

Imagine your big screen television goes on the fritz. You wind up at ABC electronics store and look at the huge wall that is completely covered in HD, LED, LCD, 3D, UHD and curved televisions. Where do you begin?

At the left side where the prices are lower and quality, size, and features are limited or the right side where enhancements are plentiful and screen sizes seem equal to a movie theatre, with prices to match? Or do you rely on the salesperson to help guide you through these steps? We are playing the role of the consummate salesperson where our job is to guide our patients to a reasonable choice and help them understand why we are selecting a particular appliance and the advantages it offers them.

My decision process starts with the examination. My dental exam leads me towards the first of several algorithmic and logical decision pathways. For example, if there are normal teeth in quantity and quality present, I have the most choices. I can select a flex material, vinyl material, hard acrylic or thermo acrylic, I can choose Cad/Cam milled, or 3D printed. If teeth are compromised due to the presence of large restorations and the future dental needs will be higher than average, I tend to select hard acrylic as the material of choice as it allows chairside or lab modification when the dentistry is completed or is in the process. Temporary crowns are a perfect example when a chairside modification allows continuous OA therapy during restorative treatment.

Another major issue I pay particular attention to is, does this patient have any TMJ concerns? Examples are history of trauma to head neck or face, clicking, locking or limitation of movement/range of motion? If the patient has had a history of TMD or current symptoms, first we have to decide if we really

How do we make decisions based on individual patients and their needs?

Dr. David Schwartz has been a practicing general restorative dentist in the Chicago area since 1988.

He is a graduate of Indiana University and the University of Illinois College of Dentistry and enjoys all fields of dentistry with a concentration in Dental Sleep Medicine for the last 19 years. As the first user of the Somnodent MAS in the US, he brings a wealth of experience to the dental sleep community and as such he has educated many dentists around the world on the benefits of dental sleep medicine. He has lectured at various study clubs and dental organizations including LVI, Northwest Indiana Dental Society, Chicago Dental Society, Itamar Corporation and Somnomed. For the past two years he has, along with other faculty members, created the Board Review Course given annually to better prepare those candidates for taking the American Board of Dental Sleep Medicine examination. He was also the Chair of the Advanced course for the AADSM in 2013. He has served on the Insurance Reimbursement Committee, Accreditation Committee and now on the Board of Directors for the Academy of Dental Sleep Medicine. He is a Diplomate of the American Board of Dental Sleep Medicine. He is co-author on a paper â&#x20AC;&#x153;Sleep Medicine Care Under One Roof: A Proposed Model for Integrating Dentistry and Medicine.â&#x20AC;? He is currently director of Dental Sleep Medicine at The Center for Sleep Medicine in the Chicago-land area locations.

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CHOOSINGappliances want to treat them or should we encourage the patient to try CPAP therapy. Every dentist will have different comfort levels depending on their training and expertise.

Depending on what TM dysfunction I diagnose, I usually add an anterior discluding element or ramp onto the sleep appliance. I tend to steer away from rigid dorsal designs that do not allow lateral movement unless I can add that feature. This can be done in hard acrylic or the softer combination material. I may chose to make for instance a Narval appliance for these patients but then add an NTI device by utilizing a lingual strap design with special instructions to the laboratory. Your treatment choices may vary; these are examples of what my protocol is in certain situations.

Patients have to be evaluated with regards to their specific periodontal concerns. In the same light as TMD what do we

use for those patients who are bruxers?

This is a very difficult discussion as we all have our theories regarding bruxism and sleep and the best way to handle it. Will the sleep appliance alone alleviate the bruxism drive by opening the airway? Or should we utilize the materials of our device to allow for these forces to be effectively handled?

I like to preemptively provide some adaptive mechanism to help these patients.

It might be the utilization of a flex type material to absorb more pressure while grinding and clenching or the use of an anterior discluding element described in the previous paragraph. For the heaviest of bruxers, I will utilize a SUAD or the Narval with an NTI (yes two separate devices) to decrease the activity of the muscles of mastication.

How do I handle patients that have obligate oral breathing patterns?

Many of my patients have nasal obstruction that is seasonal and related to allergens or humidity. Others have physical obstructions that require treatment by our Otolaryngology colleagues to correct airflow. It does not make sense to fit one of these patients with an anterior restrictive type appliance such as the TAP series of devices. Many of my patients find that inability to open too restrictive; it makes it difficult for them to be compliant with the device. While the TAP is a great choice for patients who have nasal patency, it becomes a concern for those

40 DSP | Summer 2015

patients who have anterior recession, significant crown and bridge history on the front teeth or proposed treatment in that region.

Do you utilize the same appliance for a patient who opens wide enough to fit an apple in his mouth versus a grape?

For the large-mouth individuals or those you see that have a very short mandible, a micrognathic appearance or are severely Class II with immediate retrusion when opening, I typically choose a rigidly fixed appliance to keep the maxilla and mandible tightly held together. An appliance such as a TAP comes to mind first. Certainly adding elastics to a dorsal appliance to hold the jaw together is a good option too. Similar types of retention would be the EMA, Narval, PM Positioner.

What do you use for patients who have had periodontal problems or anterior grafting procedures?

For many of us doing oral appliance therapy for sleep apnea treatment, the mere mention of periodontal disease and bone loss eliminates the use of an oral appliance as a treatment option. Patients have to be evaluated with regards to their specific periodontal concerns. If I feel that the concerns are negligible, than I will proceed with the use of an oral appliance. In a patient with anterior bone loss, I will rarely use a TAP appliance as this puts an undo amount of stress onto those front teeth. My choice for these patients is the Narval by ResMed, which eliminates the pressure on the front teeth by the design of the appliance itself. I will also consider a hard acrylic appliance and a dorsal type mechanism, as this will keep movement of the anterior teeth to a minimum while splinting the teeth like a retainer.

I encourage these patients to maintain their preventive care frequency and home care. In severe cases, they can have the anterior teeth splinted with extra-coronal retention prior to fabrication of a device.

One aspect of appliance selection that is often overlooked pertains to the physical ability of the patient to place, remove and adjust the appliance. This can be due to age, arthritis, tremor, diminished mental capacity or other issues. Many years ago, a Vietnam

CHOOSINGappliances Veteran that came to me as a patient humbled me. He was limited physically as a triple amputee, losing two arms and a leg in the conflict. He was desperate to treat his apnea and CPAP was not an option. His arm prosthesis was the old hook-and-claw type. The ability to use his arms was severely limited to rudimentary movements with minimal fine skills. Was a TAP appropriate? A two-piece dorsal? PM Positioner? Clearly his case was a challenge and after much discussion and a few appliances later, we ultimately selected a modified PM Positioner that had an extension handle on the maxillary arch to allow him the ability to place and remove the device. The adjustments were done by his wife or by me and after a few weeks he was happy to have relieved his sleep issues. The point is that we had some trial and error associated with his treatment, but I learned that not one appliance can be used to treat everyone.

There is no magic pill and we have to use our skills, experience and creativity to select appliances for our patients.

Is it wrong to select an appliance based on profit â&#x20AC;&#x201C; making a business decision that influences a clinical one?

(Picture me with a long dramatic pause in my breathing as I begin to discuss this.) We all have concerns about profit and yes, when you do several hundred of these devices in a year, the difference between a $500.00 appliance and a $300.00 appliance makes a significant improvement to the bottom line.

For those of us treating Medicare patients a lower cost alternative is already designated by the rules of which appliances we may use. In my practice, our insurance contracts specify an amount; the lab cost is already factored in. If for example the contract reimbursement is $600.00, it is hard to justify the higher cost appliance for that patient. If the contract disallows balance billing, we have to select a device that is effective and also fits within our patients insurance coverage. I liken this to generic drugs versus name brand drugs or equivalent benefit drugs. By comparison, imagine if you will a prescription for Celebrex, an effective Cox 2 inhibitor. This is a wonderful class of drug but is also expensive and many insurers do not cover that due to the high cost. Usually the doctor, or more

commonly the pharmacist, will recommend an alternative medication such as Naproxen, which is equivalent on the pain but may lack the protection against stomach irritation. The patient may have the option to pay for the Celebrex but ultimately it is their choice. It is my opinion that we have the right to choose an appropriate appliance based on the cost benefit to our patient and to us.

There are many factors that go into choosing an appropriate appliance for our patients. To attempt to classify all of them is daunting. It is our job and duty to do so with consideration of the many details that come with treating patients as individuals, with unique dental concerns, physical limitations, wishes and desires. We run a professional business, also, with its obligations. Sorry I could not give you an algorithm to make the choice clear for each person you see; I hope you have been inspired by this essay to think about those details and make the choices for your patients easier.

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41

BILLINGsystems

What Sets a Successful DSM Practice Apart?

Panel Discussion with Rose Nierman, Randy Curran, and Courtney Snow

E

xperts from Nierman Practice management discuss why some practices implement dental sleep medicine (DSM) quickly while others struggle to get going.

Rose: We have helped thousands of practices acquire success in DSM treatment and notice some practices soar while others struggle to get going. You both work with all types of practices day in and out. What major Rose Nierman differences have you identified between practices that go from 0 to 20 OSA patients in 6 months or less and those that take longer to get there?

Courtney: For starters, practices that adopt a “medical model” and properly communicate that model to patients and the medical community are the most successful.

Rose: Case presentation is integral when converting to a “medical modCourtney Snow el”. Dental insurance is quoted to the penny whereas medical insurance is more of an estimated amount.

Randy: The biggest hurdle I hear; “the patient does not want to pay thousands of dollars out of pocket”. If they only have to pay $500 to $800 out of pocket, then it’s easier to get going. If offices are only converting about 30% to 40% of patients, a true medical billRandy Curran ing model for your dental sleep patients makes the difference. Or at least consider how to offer these services to patients who don’t move forward because of the up-front costs.

Rose: This also helps when marketing to the medical community. Physicians tend to refer to dentists who can minimize their patients out of pocket cost so they can get treated.

Courtney: The benefit verification is a crucial part of the process, to ensure the rest of

About the Authors: As specialists in the “medical model” for Dental Sleep Medicine and TMD, Rose Nierman, Randy Curran and Courtney Snow support dental practices and present seminars, nationally, to dentists and their teams. To contact Nierman Practice Management, visit www.dentalwriter. com or call 1-800-879-6468.

42 DSP | Summer 2015

the process goes smoothly! Determine the patient’s deductible, co-insurance and potentially the in-network benefit (GAP). Once you have this information, you can estimate the patient’s out of pocket expense.

Randy: Yes, and the insurance carrier’s usual and customary comes into play. Three of the major insurance companies (United Healthcare, Cigna and Aetna) will usually allow an average of 75% of the charge amount if the plan is well funded. You will learn more in your area to help estimate as you see EOB’s (explanation of benefits) come back and establish a payment history.

Courtney: When outsourcing the billing, a good medical billing company should be able to coach on how to present to the patient. Randy’s the best in the business on that!

Randy: Well thanks, Courtney! The first thing I ask new clients is how they present benefits to patients. Many practices have trouble getting case acceptance and communicate patient benefits with a somewhat pessimistic tone, which inadvertently tells the patient the treatment isn’t worth the cost to them. When you haven’t met your deductible, does your doctor ask you if you still want to move forward? It’s better to say, “We have great news Mr. Brown, your medical insurance does cover this, and we expect your out-of-pocket to be X dollars. We work hard to get you GAP coverage to get you better coverage”.

Courtney: Successful practices take the time and resources to train their team and understand protocols, billing and referral processes. And, in my previous position as the medical billing coordinator for an oral appliance company, we saw practices that had a system and others who did not. Even when outsourcing the billing, I noticed that those with the system had the most success. Rose, you’re the expert on systems.

Rose: Thanks, Courtney – that is a big part of the medical model. A note “saw pt. for an appliance consult” vs. generating a SOAP report with subjective symptoms, oral/airway exam, assessment and plan can make all the difference in getting paid. And impress your referring physicians, to boot!

ASSOCIATIONbenefits

g n i t t e G d e t c e n Con

M

ABDS DMD, , s r e g o

rt R. R

e

by Rob

A

s I pen this article, I am amazed at the intense interest in dental sleep medicine and the widespread good it is doing for millions of patients worldwide. The efficacy of oral appliances is well supported in the scientific literature, physicians are actively seeking dentists to become part of the treatment team, insurance carriers cover a significant proportion of the cost most often and great numbers of patients are clamoring to avail themselves of this “new” technology. My goodness, there is even a magazine dedicated to the practice of dental sleep medicine. This one!

This was not always the case. When I first stuck my toe in the water in 1990, none of the above existed. I was using a non-adjustable “boil and bite” appliance (state-of-theart at the time) and treating about one patient per month from my dental practice with variable results. No referrals from physicians. No pre and post treatment sleep tests. No real clinical protocol. Never even heard the word “titration” as applied to oral appliance therapy. These were not easy times. Physicians thought that the few dentists who offered this service were quacks out for a quick buck.

And we had a difficult time convincing them otherwise due to the dearth of scientific literature regarding oral appliance therapy. Fly-

44 DSP | Summer 2015

ing by the seat of our pants seems to describe it accurately.

In the absence of any kind of formal organization to learn from or network with, I and a handful of other pioneers set out on an arduous journey to support each other in this nascent endeavor. We formed a tiny study club and met via conference call each month to review our progress or setbacks. (Notes of our meeting were created on a typewriter!)

After a year or so, we put an ad in the ADA Journal soliciting members to join our proposed “society” which we named the Sleep Disorders Dental Society (SDDS). To our great surprise 75 dentists responded and we were off and running. I was selected to serve as the Founding President and we ran the entire organization out of a spare bedroom in my home for 10 years with my wife Mary Beth being our first Executive Director.

As the years passed, we grew slowly and gradually gained the respect of the medical profession as research on oral appliances began to appear in the literature. Ultimately, we changed our name to the American Academy of Dental Sleep Medicine (AADSM) and moved our headquarters to Darien, Illinois to be managed by the American Academy of Sleep Medicine. This partnership has been fruitful over the years allowing us to quick-

ASSOCIATIONbenefits ly expand our membership, produce review papers and standards of care, offer worldclass annual meetings, and basically become a respected part of the medical team.

From these humble beginnings, the AADSM now represents a unique opportunity for dentists to discover the basics of dental sleep medicine and develop expertise therein over the years. Membership in the AADSM (www.aadsm.org) offers countless benefits: • A discounted rate at the annual meeting with the opportunity to meet some of the finest researchers and practitioners in the field • Discounts on educational courses given throughout the year (Essentials, Advanced, Practical Demonstration, Study Clubs and the Board Review Course) • Access to the Journal of Dental Sleep Medicine • Access to the Find-a-Dentist site for patients who need a sleep disorders dentist in another city • Management tools (Marketing, Educational Slide Collection, Insurance Support Packages, Procedures and Codes for Reimbursement, Sample Letters) • Insurance support and advocacy with third-party payers and the FDA • Opportunity to get involved on a committee level with organized dental sleep medicine • Enter the AADSM research award competition and submit a poster presentation at the annual meeting

• Online access to the website to keep you up-to-date with the news of the field of sleep The pinnacle opportunity is to achieve Diplomate status from the American Board of Dental Sleep Medicine (ABDSM), a testing organization independent from the AADSM. Diplomates are recognized in the dental and medical commuAADSM represents nities as those dentists who have put forth the time and effort to raise their a unique opportunity skills to the highest level. We believe for dentists to discover Diplomate status is going to become crucial with the present evolution of the basics of DSM healthcare and possible future guidelines from Medicare. In addition, dentists who are planning to participate with medical insurance carriers, credentialing may very well be dependent on being a Diplomate.

Achieving Diplomate status is contingent on meeting certain requirements including but not limited to passing a 200-question multiple-choice test and the submission of a number of case studies. The ABDSM (www. abdsm.org) is continually working to accommodate members’ unique situations to make a fairly rigorous endeavor as easy and smooth as possible.

What a difference 25 years can make!

Dental sleep medicine is the fastest growing field in dentistry today and one of the most rewarding. Consider jumping in with both feet. Membership in the AADSM is a good way to start.

Dr. Robert R. Rogers has had a special interest in the treatment of sleep-disordered breathing since 1990 and treats patients in conjunction with many regional sleep centers. Presently, he is President and Director of Clinical Services for Pittsburgh Dental Sleep Medicine, PC and limits his practice to dental sleep medicine.

Dr. Rogers is the founding president of the American Academy of Dental Sleep Medicine (AADSM) and served again as president in 1995 and 1999. In addition to being a long-term member of the Board of Directors, he has participated in committee work on a consistent basis. Dr. Rogers is a Diplomate of the American Board of Dental Sleep Medicine and is the recipient of the AADSM Distinguished Service Award.

Dr. Rogers was the author/editor of the original AADSM educational slide series and is a contributing author to the graduate dental text, Clark’s Clinical Dentistry. He is currently the dental consultant to Philips-Respironics, Inc. Dr. Rogers was a member of the task force for the revision of the American Academy of Sleep Medicine Position Paper and Practice Parameters on Oral Appliance Therapy. He also co-authored the American Academy of Sleep Medicine Guidelines for the Evaluation, Management and Long-term Care of Adult Obstructive Sleep Apnea. In addition, he is a consultant for the National Institutes of Health regarding oral appliances as related to the treatment of sleep-disordered breathing.

Dr. Rogers is a frequent speaker at the AADSM Annual Meetings and has presented lectures on oral appliance therapy to physicians, dentists and patient groups throughout the United States and Europe.

DentalSleepPractice.com

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MARKETING

by Rod Willey, DDS, DACSDD

“I

’m not in this for the money, I just want to help people and really make a difference.” Joe, a typical dentist, voiced the sentiments of so many conversations I have been in over the past five years and I could not agree more. Life is difficult and when we dentists have the ability to ‘make a difference in a life’ it is our privilege and responsibility to do so.

However, before we can help them, we must recognize the reality that unless we learn to market our product effectively, we will never sell it to the masses that are desperate for it. We are then disappointed in the results and realize we only helped a fraction of the people we are meant to serve. I learned long ago that ‘selling is service’ and without it, there simply is no business.

If we believe in what you are offering the world, it is our duty to learn to sell it so the greatest number of people can be served. At Koala Center for Sleep Disorders, we do a few things in marketing you might find interesting. Here are some strategies:

1. Educate

Millions of people who need OSA treatment are unaware of the oral appliance therapy that you offer and clearly are not actively shopping for you. They have not thought of your office or made a decision to enter your office for treatment – you must reach them and earn their business. We believe our finest moment is when we educate, opening doors people did not know were even there.

Educational Marketing is the most ethical type of marketing. It sets you apart as a ‘giver’ in a world that is often focused on ‘taking.’

You will be known as someone who is trustworthy and patients-to-be will want to hear what you have to say.

Educational Marketing is the most cost effective form of marketing. It gives you access

46 DSP | Summer 2015

to the patient-to-be who has OSA symptoms yet unaware of the treatment options available.

2. Brochures

It is always surprising to me when I come across someone who believes brochures are old fashioned and out dated. Well, let me assure you that patients and patients-to-be want to know all they can about you, your staff and what you provide. A well-done brochure will capture interest and educate those who need your help.

3. Over the Top Business Cards

Your business card may be your smallest marketing source, but it’s also your most important. Patients-to-be and business prospects hold on to business cards so you will want to make your message count. Carry them with you at all times and liberally share in every appropriate circumstance.

4. Newspaper Articles

Newspapers are another marketing venue that many believe is out dated. There was a time when I was tempted to believe the same thing until I spent an evening at Barnes and Noble and noted the many people who were reading the newspaper.

Done well, a newspaper ad will position a patient-to-be to make a purchase. Ads create value; the content is educational and is strategically structured to lead your patient-to-be to logical conclusions that they need what you are offering. The ad will create urgency through reports, interviews and statistics.

A well-done ad is a message designed to reach an audience with a 12th grade edu-

MARKETING

cation. It states the problem and shares the answer in terms that are not scientific, but human.

5. Word of Mouth

Word of mouth marketing can make or break your practice and reputation. Invite your customers to be your ambassadors. Provide them with tools such as brochures and key talking points that are easy to remember and pertain to their treatment.

Word of mouth marketing is, at its heart, using happy customers to promote your business â&#x20AC;&#x201C; nothing less than walking billboards wearing your name. The key to word of mouth marketing is to provide your patients with such unbelievably amazing, life-affirming treatment and service that they canâ&#x20AC;&#x2122;t help but share their experience with friends, family, co-workers, and the stranger in the grocery store line.

6. Use a Microphone

Social media is in-your-face yet essential â&#x20AC;&#x201C; some refer to it as a love-hate relationship.

There are many voices your patient-to-be is listening to, so you must speak with a microphone. The largest microphone we have in marketing today is social media. Social media allows you to leverage your message by taking the same piece of content and putting it into several different templates and distribution venues. Take what you have done well and use a microphone to reach the masses.

For more information about joining the Koala Centers for Sleep Disorders, please visit their website at koalasleepcenters.com or call 971-245-5360.

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START-up

David Gergen on Koala Sleep Franchises Marketing and Expansion

D

r. Rod Willey, who founded Koala, has been my largest account since he started doing dental sleep medicine three years ago. In one amazing month he started 106 cases! Month in and month out, Dr. Willeyâ&#x20AC;&#x2122;s practice is starting 60 cases. His second franchise also is hitting that 60 case a month level. He has this proven track record and I believe it is because he knows how to market.

Each Koala practice is marketed differently, based on the demographics of each location. Dr. Willey focuses on the specific area and markets heavily, directly to the public, to precise target prospects. The new Koala of Arrowhead opening in Glendale, Arizona in May 2015 will follow this same successful pattern.

Hereâ&#x20AC;&#x2122;s some perspective: we work for 3,000 sleep dentists around the country.

The majority of the doctors only do a few cases a month. When they reach 20 prescriptions a month, we consider them to be a solid account. There are less than ten of our accounts that average more than 40 cases a month Dr. Willey is way above average with 60. What he is doing works!

The new Koala of Arrowhead is close to the Arizona Cardinals stadium and is working with NFL legends to tie in to that specific market for branding effectiveness.

They are also going to center TV and radio ads around this demographic.

There will be a public seminar with invited referring MDs soon after opening to generate buzz. Free education to the public and professional community is another proven success Dr. Willey implements with his sleep centers. If you would like more information on this specific center, please see the information listed to the right.

48 DSP | Summer 2015

I Scored a lot of Touchdowns in My Career

But No Score was as Big as being Treated for Sleep Apnea – Roy Green

former NFL wide receiver

Signs & Symptoms of Sleep Apnea ✓✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓✓

Loud Snoring Morning Headaches Excessive Daytime Fatigue High Blood Pressure Inability to Lose Weight Choking/Gasping Sensation that wakes you up ✓✓ Acid Reflux ✓✓ Depression/Mood Swings ✓✓ Decreased Sex Drive

You’re invited to a:

Free Seminar on Oral Sleep Appliances

• Covered by Most Medical Insurance Plans & Medicare • Comfortable Alternative to CPAP • In-House Financing Available

Tuesday, Sept. 8, 2015 at 6:30 p.m.

Hampton Inn | 8408 W. Paradise Lane, Peoria, Arizona

RSVP to 623-594-9787 or arrowhead@koalasleepcenters.com Koala Center for Sleep Disorders – Arrowhead Mark Castle, DDS 8110 W. Union Hills Blvd., Ste. 430, Glendale, AZ 85308 623-594-9787 | arrowhead@koalasleepcenters.com

PRACTICEmanagement

How I Transitioned to a Dental Sleep Medicine Practice

by Mayoor Patel, DDS, MS

A

fter graduating dental school in 1994, I was ready to begin my career and to improve people’s oral health. Two years later, I had opened two successful dental practices and was a drilling and filling machine. I enjoyed seeing and helping my patients, but the challenge and excitement was diminishing and I knew I could do more for them. I was a young and curious dentist with a lot of questions. When I started seeing correlations between patients’ responses to my questions and headaches, pain, problems sleeping and serious health issues, I realized I needed to do something more, but it took me almost a year to figure out what.

In 1997, I heard Dr. Henry Gremillion and the late Dr. Parker Mahan discuss TMD treatment at the University of Florida. I still remember the excitement running through my head on that drive back from Gainesville.

I finally had the answer and committed to treat patients with craniofacial pain and TMJ disorder. I knew it would be a process, but I also knew my patients well enough to understand just how many lives I could change.

50 DSP | Summer 2015

I had two major questions: • How can I avoid the “trial by error” approach to helping the more challenging patient cases?

• How do I get paid for the value of my services, without limiting the patients I can help?

I embarked on a journey to learn as much as I could, beginning with courses on pain and dental sleep medicine from Drs. Gelb,

PRACTICEmanagement Okeson, Pertes, and Stack, to name a few and studied at annual meetings by the American Academy of Craniofacial Pain (AACP), American Academy of Orofacial Pain (AAOP) and the American Academy of Dental Sleep Medicine (AADSM).

Exhausting the resources of many gurus in the field, I had the clinical knowledge but lacked the internal systems to run a limited practice. Fortunately, at my first AACP annual meeting in mid-2002, I met Rose Nierman.

Everything fell into place. A dedicated system for tracking craniofacial pain and sleep therapy was my missing piece. As soon as we implemented DentalWriter software for medical billing, and data capturing and obtained the support, the practice grew.

In late 2002, my team was on board and we were screening and treating our patients, but that wasn’t enough to make these ser-

vices the primary focus of my practice. Other dentists weren’t referring because I performed dental procedures. We changed the name to reflect a craniofacial and sleep focus and stopped accepting new dentistry patients – a huge risk – but one we felt was necessary to achieve the goal.

We grew each year, and by 2007, after oral appliances were recognized by the AASM, dentistry patients represented less than 25% of my practice revenue. That was 8 years ago and a lot has changed to expedite this process, but it’s still a process that must be well thought out. It took ten I realized I needed to years, but by 2012, we were 100% focused on pain and sleep. do something more Along with board credentials, communicating got us recognized, respected and referred to. Referrals from medical and dental practices increased the most from the letters we send to patients’ physicians and dentists following consultation, treatment and discharge.

Those sleepless nights, tossing and turning about limiting my practice to pain and sleep paid off. We see patients three days a week and enjoy the rewards of changing lives every minute. I often get asked, “Can I limit my practice?” My answer is, “Yes. If you believe you can, you will.” Set goals, commit to the process, find experts to educate, train and support you and your team and don’t be afraid to ask for help along the way.

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

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

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

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

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FUTUREeducation

Next Steps in Navigating the World of Dental Sleep Medicine

by Dr. Erin E. Elliott

Y

ou are reading this magazine because there’s always more to learn about treating sleep apnea – I’ll get to that. But first, let me start out by telling you why I NEVER wanted to make sleep appliances in my practice. In 2008, 5 years out of dental school, one thing I was absolutely sure of was that if a patient had Class I canine guidance then all was right in the world. One of my favorite patients, Phyllis B., had that perfect bite until she came in with (cue scary music) a posterior open bite! Gasp! The horror! I furiously wrote a referral to the orthodontist to get this immediately fixed. How dare a dentist make MY patient an oral appliance to help her airway at night that could potentially change her bite.

You can even tell how mad I was by my messy handwriting. Oh wait… my handwriting is always messy. In all of his wisdom, the orthodontist sent me the consult notes that stated “No orthodontic treatment recommended at this time.” Do you know why? Because she was breathing at night, because she was getting oxygen, and because she wasn’t slowly dying in her sleep. Do you know the best part? The patient didn’t even know she had a bite change. She didn’t even care.

52 DSP | Summer 2015

FUTUREeducation Whoa! This is a life changing and career changing paradigm shift in my indoctrination. Some of my favorite quotes from the leaders in Dental Sleep Medicine include: “Open casket? Or open bite?” and “Teeth shift, get over it.” I say, “Oxygen trumps bite every time.” When I realized that not only could I help my patients smile confidently by providing life changing dentistry but that I could also help save their life by providing an oral appliance, I immediately pursued learning more about Dental Sleep Medicine.

Besides I don’t know anyone who loves to sleep more than me.

I started out simply. The Idaho State Dental Convention convened in Boise that year and had a sleep physician speak in the morning and a sleep dentist speak in the afternoon.

It was enough to get me interested. But most importantly it was enough for me to realize that Dental Sleep Medicine is more than taking 2 impressions and making a piece of plastic. It’s dangerous to treat people without a sleep study and proper follow-up. Besides, if I just started providing appliances which one would I choose? And what happens if I get a side effect or the appliance wasn’t effective enough? Like any good youth of today, I went to the internet and found an introduction course in Dallas, Texas. Dallas was a cool place to visit right? I knew nothing about Kent Smith at that time but have found him to be one of the wisest mentors around.

That was 2009; in 2015 there are many, many intro courses to choose from. Even courses

by Moi. How can you choose? Some of the questions I would ask are: Who is sponsoring it? What is the curriculum? Who is teaching it? How much is it? Do I need to buy “stuff” before I make my tuition back? Do they teach medical insurance billing? How much time/ CE credits do they offer?

Is two days really enough? Yes and no. It is enough to learn the basics of sleep medicine, the medical part. It is enough to learn dental signs and symptoms. It is enough to learn which appliance to use in which situation. Should you use just one appliance? No! So make sure you learn from a course that teaches more than just the appliance that is sponsoring the course. And 2 days is enough to learn the basics of medical billing. But 2 days is not enough to learn about the changing landscape of DSM and the in-depth medical side. There are 3 and 4 day intro courses as well provided by such groups as Pankey,

Dawson and Spear, the leaders in teaching the occlusion that was my comfort zone. LVI has a great series on DSM as they believe that airway is king when treating restorative cases.

What I did after my first 2 day course was come back to the office, try to share the excitement with my team, and start treating family and friends. I found the most important lesson during that time was learning what I didn’t know and pursuing more education.

There are mini-residencies available at both Tufts and UCLA. The American Academy of Dental Sleep Medicine has a three-day conference every year tied in with the medical branch of the American Academy of Sleep Medicine. They also have courses available throughout the year. The American Sleep and Breathing Academy – Dental Division has an annual conference in Scottsdale that is multi-disciplinary. I think these conferences are a great way to learn from the medical side and learn the dental side in a very unbiased fashion. Learning to work side by side with sleep physicians and seeing how to navigate

Learning to work side by side with sleep physicians and seeing how to navigate the medical world is imperative to treat sleep apnea in your practice.

Dental Sleep Medicine is just getting started. Now is a unique, once-in-a-business-lifetime opportunity to establish your “brand” and stake your claim to the oral appliance market in your community.

SnoremanInc.com includes:

• Domain Names • Radio & Print Ads • Logos • Office Forms & Brochure • Appliance Notes • Dental Sleep Medicine Web Pages

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53

FUTUREeducation

Continue to learn so that you can have an impact not only with your patients but your team and your community.

We are saving lives!

the medical world is imperative to treating sleep apnea in your practice. I like to say, “It is time to put the handpiece down and put the stethoscope on.” We, as dentists, are providing a dental solution to a medical problem.

There is no class available teaching you how to interact with your medical community but it can begin as a simple lunch-n-learn or an observation at a sleep lab. My entire goal is to figure out the best referral pathway for my patient. If I have a patient with signs and symptoms of sleep apnea I don’t want an uphill climb to consult, test, diagnosis, treat, and confirm effectiveness. What is the best way for my typical patient to get help? To find out, I hit the pavement. I talked to any MD and sleep physician I could, to let them know the facts and the motivation behind my ‘madness.’

There are various other academies that have advanced learning tracks in treating pain and TMJ patients such as the AACP (American Academy of Craniofacial Pain) and the American Academy of Orofacial Pain. Great teachers like Drs. Jeffery Rouse, Steven Olmos and Dr. William Hang, who is an orthodontist, also have courses for basic and advanced learning.

I get notifications everyday for webinars and I am more than happy to NOT mark them as SPAM. These have been great learning tools for me to learn from very wise dentists and MD’s in the comfort of my home; Post Falls, Idaho, isn’t, shall we say, a metropolis that these speakers come to very often.

I also read everything I can get my hands on. There are two main books that cover DSM that I ordered through Amazon (that’s the only way I shop for anything anymore): Sleep Medicine for Dentists: A Practical Overview

by Giles Lavigne and Dental Management of Sleep Disorders by Dr. Dennis Bailey and Dr.

Dr. Erin E. Elliott is a graduate of Creighton University where she graduated in the top 5 of her class. She has been a general family dentist in North Idaho for 12 years where she has taken a special interest in screening and treating patients for snoring and sleep apnea. She has authored several articles and has lectured and trained other general dentists in this important area of dentistry. She is actively involved in her community and is an active member of the American and Idaho Dental Association, American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and is a diplomate of the American Sleep and Breathing Academy.

54 DSP | Summer 2015

Ronald Attasino. This may reveal my nerdy side but I also got my hands on a medical school Sleep Medicine textbook. The exciting part in the dental world is how many articles are coming out in our professional journals and magazines; the launch of Dental Sleep Practice last year is case in point! The more that dentists know how to screen patients and get them to proper diagnosis, not be content to stop with snore guards, the more our world will be a better place.

I am a member of several forums. The Wasted Day and Sleepless Nights, Dental Nexus and Sleep Better Northwest forums have made me a better sleep apnea dentist.

This is where I think the real-world, case by case learning occurs. I feel blessed to be a part of a community that provides a continuous opportunity to learn and to be better clinicians and to navigate the ever-changing landscape of DSM. The most difficult part of learning anything is incorporating it into the practice.

All the head knowledge in the world will not help you if you aren’t treating cases. The best advice I can give you is to implement systems and protocols into your practice by training every single member of your team.

I’ve made many mistakes over the 6 years I’ve been doing this and mistake #1 was not having everybody from front to back helping in the screening, treating and billing. The chain is only as strong as its weakest link. There are sleep dentists and other types of trainers who will come to your office to train your team.

One resource I’ve just learned about is OSA University – they have online training for teams, so you don’t even have to go on an expensive trip to get your people up to speed.

Let me leave you with this… get trained and get trained now. Continue to learn so that you can have an impact not only with your patients but your team and your community. We are saving lives! When you actually put the training to use each and every day is when you have the most impact. At a recent course I taught, I had each of the 30 team members focus their energy to put out a candle lit in the middle of the circle.

We sat there uncomfortably, waiting for their positive thoughts to do something, for a full minute before I finally got up and blew the candle out. The moral of the story? All of the education and positive thoughts in the world will do NOTHING if you don’t get off of your derrière and take action!

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PAPinfo

CPAP 101: The Dark Side of the Moon

by Rob Suter

C

PAP is the gold standard for OSA therapy, yet many dentists doing sleep appliances have had very little training on the topic and consider it the “dark side of the moon.”

I have worked on the CPAP “dark side”and now on the dental sleep side and found that both sides have much to learn about the other. I firmly believe more treatment algorithm infrastructure and education on both sides is needed in order to successfully treat more SDB patients. In this article, I would like to share some foundational knowledge, lingo and definitions of the CPAP side. Dentists trying to speak to MDs and DMEs in their town need to comprehend the lingo; this involves a better understanding of CPAP, DMEs, Sleep Labs, and compliance monitoring. When I listen to dental lectures, I sometimes hear things like, “Nobody ever wears CPAP” or “CPAP compliance is 40% on a good day.” Some brag about all the patients they have taken off CPAP, because “no one wants to wear a mask on their face.” Dentists, be careful about who you listen to: if that’s all you hear from dental conference training, or if every patient’s story is about their CPAP problems, your view of that therapy may be tainted. It’s like police officers who deal with thieves, liars, and crooks all day developing a cynical attitude towards human nature.

56 DSP | Summer 2015

As the former Regional Manager for Resmed’s Dental Sleep team and now the VP of Sales for osauniversity.org, I have a unique view of the Sleep world because I met the best and brightest sleep minds: Sleep MDs, DDSs, Hybrids, DMEs, RRTs and sleep lab techs. Working for ResMed, the global leader in sleep therapy, I was impressed with the hundreds of engineers creating solutions for SDB, from specialized VPAP devices to the first CAD-CAM MAD, the Narval CC. With so many choices for helping OSA patients, why is it that less than 10% are ever offered a 2nd line OSA therapy? When someone scans other areas of medicine such as depression, CVD, and asthma, there are clear protocols in place for what happens if the patient doesn’t respond to 1st line therapy. Cardiologists have JNC7 that outlines treatment algorithms for hypertension. Neurologists have the DSM V for depression, and pulmonologists have the ATS guidelines for asthma and COPD. All these manuals clearly elucidate and automate 2nd and 3rd line therapy algorithms for health care professionals to follow. Specialists know where patients are going, and hence so do the patients. Sleep apnea specialists have minimal centralized treatment algorithms, and most importantly, typically only 1st line therapy is shown to

PAPinfo the patient. Or if another modality is shown, its from 1978 and is meant to scare the patient into the device of choice. We as sleep professionals need to address this issue, so everyone involved can be clear that it’s not a matter of what device is used first, CPAP or MAD: it’s about adherence to one or both. When either first choice fails, the patient should go to 2nd line therapy like clockwork, not if the patient reads a jaded billboard, ‘Do you hate CPAP?’ I hear Sleep MDs boast that their CPAP compliance is 90%, so they have no need for VPAP rescue or referring to a dentist because all their patients are adherent. I helped write a wireless CPAP compliance study where we took a hard look at a strong DME that had terrific patient follow through (Sleep Diagnosis and Therapy Vol 6 No 4 June-July 2011). The ironic part of the study was that the Hybrid DME and MDs thought their compliance was 92%, and thought the study would validate their success. However, after closer analysis and using CMS compliance standards, their adherence rate fell to a more normal level – 62.5%. Many times when I dig in to compliance claims, I find MDs and DMEs measure compliance differently. Many do not track the patients who reject therapy or do not go back to see them. See no evil, hear no evil; those patients are simply not counted and fall off the grid. This is the most troubling trend I see in our SDB market, and it needs to stop. In my opinion, dentists need to delicately confront and provide their sleep solutions.

Think of Sleep Docs as proud new parents sitting in the audience at a school play: they only see how smart, pretty, and funny their kids are. The Sleep Docs only see the patients that are doing what they were told. Life is grand on

the dark side of the moon for the Sleep Docs; it’s the DMEs who handle the tough calls on mask and humidifier issues. The patients that are enjoying CPAP show up for their appointments, the compliant ones who are trying to make CPAP work for them. The Sleep Doc says, “Looks like you used your device 45.5% of the last 45 days Mr. Jones. I want you to try to use it more Mr. Jones” and sends them on their way.

Meanwhile, the non-compliant patients call the DMEs and try to get help or new supplies.

They get really frustrated because they’ve paid a lot of money, they can’t get comfortable in the mask, and now they have CPAP-induced insomnia! They show up angry in a dental chair and rant and rave about how much they dislike CPAP. This galvanizes the dentist’s perception ainto an anti-PAP slant...nobody is wearing those masks they wrongly assume. Truth be told, companies like ResMed track adherence from a higher vantage point, gathering non-patient-identified data. Use of PAP therapy is higher than most dentists think and lower than most Sleep Docs want to admit. There is a reason that ResMed is a billion dollar company, and it’s not because of MAD therapy; millions of people successfully use PAP every night. It is the gold standard for a reason.

I would encourage you to review and get to know the following terms and definitions.

They will help you know the lingo and potentially explore new medical relationships so that you treat more patients in your practice.

Good luck in your conversations, and I would encourage you to try the questions at the bottom. They are My trusted and tried pearls of wisdom. Sleep well.

Bonus question: Tell me what organ in the body doesn’t need oxygen?

Rob Suter has over 10 years of respiratory, dental, and sleep experience. He is currently the VP of Sales for osauniversity.org, a unique and novel online school that can train dental team members on how to implement and optimize more sleep medicine in their practices. He worked for ResMed as the first Regional Manager, leading the North America Dental Sleep division for 3 years. Prior to that he worked on the CPAP, HST, and Ventilation side of the business for many years helping 50+ new sleep MDs, sleep labs and CPAP dealers launch and become profitable in the Chicago area. His passion lies in helping build medical-dental alliances and clinical models so that more patients can get treated.

He has spoken internationally at the AADSM, ASBA, Spear, and AACFP meetings as well as many other dental sleep conferenes training dentists how to communicate and work together with the CPAP providers to treat more non-adherant patients.

From a clinical perspective, Rob has done over 100 bi-level CPAP and Ventilation titrations on very complicated patients at major teaching institutions. He published a paper on wireless CPAP compliance and CPAP rescue published in Sleep Diagnostics and Therapy in 2010. He resides in Chicago with his wonderful wife and two children. Rob can be reached at rsuter@osauniversity.org.

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PAPinfo

Glossary

CPAP: stands for continuous positive airway pressure. CPAP is a medical device that blows humidified air into a patient’s airway at night. This mechanism is highly effective at treating OSA patients and typically has good patient compliance if the mask fits properly. Every year millions of patient accept and adhere to therapy, but almost 1,000,000 patients* refuse or quit CPAP in North America.

CPAP pressure: measured in cm of water pressure, CPAPs have a range of 4-20 cm and are prescribed by the sleep physician at a set pressure. Used with a humidifier that is an add-on medical device that attaches to the CPAP and holds water in a tub. Humidifiers are used on nearly all patients to reduce dryness and pressure side effects.

AutoPAP or Auto: Autos have a flowbased algorithm and a similar range to CPAP 4-20 cm, but its air pressure automatically adjusts itself based on a flow sensor that detects the status of the airway. If the airway is closing, the Auto increases pressure to prevent apneas from occurring; if the patient snores several times, the pressure will likewise increase. If the patient has positional OSA and rolls onto their side, the Auto will detect this and decrease pressure. Autos are sometimes used in lieu of a titration sleep study when a specific pressure is determined.

Bi-level or VPAP/BiPAP: these are the most complex and expensive PAP devices.

They have an inhalation pressure (IPAP) and an exhalation pressure (EPAP) that is at least 4 cm lower. These devices can have various modes of therapy, special algorithms, various comfort features and generally provide more data to MDs. Bi-level is used for complex sleep apnea, severe OSA, higher pressures, central sleep apnea or patients that need ventilation assistance such as COPD and neuromuscular patients. VPAP Auto, like MRD, is used frequently for noncompliant CPAP patients. Typical VPAP Auto pressures range from 4-25 cm and a delta between the pressure is 4-5 cm (IPAP/EPAP).

Mask or Interface: a medical device that delivers the air pressure by creating a light seal on the face. There are three main types: Full Face Masks or FFM: delivers pressure into nose and mouth at same time; largest and heaviest masks that are used for mouth breathers, higher pressure needs, and patients with poor nasal airflow.

58 DSP | Summer 2015

Nasal Masks: delivers pressure into the nose; medium size.

Pillow Masks: delivers pressure into nares only; lightest and simplest masks but typically are not comfortable at higher pressures CPAP Compliance, Payors, Data cards and Modems: compliance is measured by Medicare standards; currently 4 hours per night or more, 70% or more of a 30 day window, within the first 90 days. Hence a patient for most insurance companies must use their device >4 hrs for 21 days out of 30 days at least one time within the first 90 days of therapy. If they fail to reach this compliance %, the DME picks up the CPAP after 90th day because the patient is now considered noncompliant or NCOSA. Some payers or insurance companies won’t continue paying for NCOSA patients. This is measured by downloading a data card that comes with CPAP or a wireless modem that gives on-demand compliance data.

DME or Durable Medical Equipment: primary service provider that has trained respiratory therapists that ‘set up’ new patients on CPAP, APAP, or Bi-level. A typical set up will be around 1 hour and entails CPAP, mask, and humidifier instruction in the patient’s home or in the DME office. DME’s are the key to CPAP compliance and typically check in with new patients several times to ensure the patient is using their device properly/adequately, and that mask is fitting well. DME size is described by number of setups they do: 20+/month is a good size, 50+/month is considered big. Examples: Apria, Lincare Sleep Lab: primary site where SDB patients get diagnosed. Patients have a CPAP titration study in the lab and the sleep technologist ramps the pressure to the level that stops their apnea or events. MD then reads the study and RX’s that CPAP pressure to a DME company.

If patient only has a home sleep study, with no opportunity to apply treatment during the sleep study, they are often prescribed an Auto which can then determine successful pressures with the built-in algorithm.

DDS opportunities: Sleep MDs: ‘What are you doing with your pap refusers Dr. MD?’ DME’s: ‘What are you doing at day 91 with non-compliant CPAP patients?’ Labs: ‘What do you offer patients that can’t tolerate pressure and/or mask in their sleep study?’

TEAMfocus

Sleep l a t n e D

Team

E D A R T S T E R SEC

Varga, e n i n n

by Gle A, CTA AAS, RD

I

n the spirit of our “How to” issue, here are some dental sleep team trade secrets for every position in dental sleep medicine.

Keep in mind each office is unique and although these secrets may be organized under certain positions does not mean your office should change your operating systems. These are organized for explanation purposes only. Most team members may find themselves applying one to all of these secrets in one or multiple positions!

The Gate Keepers are those answering the phones and talking to the patients at first contact. The trade secret in this position is to schedule the patient to come in and evaluate his or her situation. The shorter the call the better! Although those in this position should be highly educated in sleep the key to this position is to schedule every appointment.

60 DSP | Summer 2015

The Informers are the dental assistants or treatment coordinators that will be with each patient from the first appointment to longterm follow up. This position is responsible for 80% of the patient’s experience with oral device therapy. Trade secret: Develop a system that works for documenting SOAP notes, informed consent, checklists, office forms, follow-up, and communicating with the rest of the team. In most cases you will find this by modifying your existing dental software and or using an electronic health record specific for dental sleep medicine. If you are using both, organize what will be tracked and where. If shopping for a DSM software, ask about special features to minimize the use of double entry. When researching and watching demos, see if you and your team can visualize using it everyday.

The Enforcers are the office managers and or insurance coordinators that are re-

TEAMfocus sponsible for making sure all the rules are being followed. This may require multiple positions. Front office requests copies of sleep tests, dental assistant works with patients to get the prescription and hygienist reminds patients to wear their AM aligner. Trade secret: Chart checklist. Create a checklist with all-team-access so each task can be checked off and evaluated.

The Marketers are responsible for getting patients to call the practice and or developing relationships with referring physicians and DME companies. Trade secret: Make sure the gate keepers are ready for all the specific questions, the team is functioning with one unified message and your marketing efforts are C-PAP friendly. If patients are asking for oral devices, find out where they heard about you and concentrate your marketing efforts there.

The Educators are the hygienists, as they have a great opportunity to talk to the patient about sleep related breathing. Trade secret: Relate signs and symptoms to each patient.

Make sure patients understand the importance of obtaining a diagnosis and treating obstructed sleep breathing and how it impacts overall health and wellness.

The Doctors Trade secret: Nasal breathing! Our industry is focused, as it should be, on the oral airway. However, the nose is equally important; look in to offering patients options to maximize nasal breathing such as the OASYS appliance design with nasal dilators or Max Air Nose cones that can be used with any oral device. Trust me – patients will be thanking you!

The Closers are the financial coordinators that explain to our patients that we are working with medical insurance companies at a

time when we cannot guarantee the payment amount. However, we will work with their insurance to maximize benefits. Trade secret: Financial contracts. Have a financial contract the patient signs, agreeing to payment. This can explain situations such as the insurance benefit going to the patient and long term follow up appointment cost.

The Chasers are those brave folks that deal with the medical insurance companies and fight for GAP waivers and in-network benefits for deductibles. I hold a great deal of respect for this position as this is where I started my career in dentistry 19 years ago in a dental office. Trade secret: Tracking!

Whether your office is doing all the billing or you have hired a third party biller, it is important to track everything! This is the best way to have insight on future insurance payments based on past processed claims. This is also the best way to stay on top of both the insurance companies and your third party biller.

Hopefully, these “Trade Secrets” are not really secrets to you but more of something you’ve known all along and now it’s time to apply them to the dental sleep medicine side to the practice. I feel patient perception is very important and everyone is the best at what they do, the more they will talk about you and the more patients you will be able to help!

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

The key is to schedule every appointment.

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

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COMBINATIONtherapy

OASYS Oral/Nasal Airway System More than moving the jaw

by Dr. Mark Abramson

W

hich is better: a kitchen knife or a Swiss Army knife?

Each has a sharp blade, but one has many more tools – you can do more than just one action. No matter how hard I try to get people to use the full name “OASYS Oral/Nasal Airway System” it gets shortened to “the OASYS” The “OA” part of OASYS stands for “Oral/Nasal Airway” for the fact that it addresses both the oral and the nasal parts of the respiratory tree, but could stand for “oral appliance”. The important part of the name is “Sys” for System. It is a system for treatment, with multiple functions all working together to get better outcomes for our patients.

The nasal dilators open the nasal valve all night long.

Oasys Lingual View with Side Activation Wrench – Easy Slide/Lock adjustment 8-15mm, forward and backward, with mm markers.

Optional Lingual Tongue Repositioner Buttons shown.

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Mandibular repositioning has been established as an effective means of treating obstructive sleep apnea. The many appliances on the market differ only in how they hold the jaw forward. Whether by means of a fin, hook, rod or a strap they all function though the same action, repositioning of the osseous structure of the mandible with the hope that the airway will expand with soft tissue tension. As we shall see, the soft tissue does not always respond to the skeletal movement.

The OASYS stands out from the crowd by adding additional actions and targeting multiple areas of the airway with one convenient appliance. It has two parts: a thin maxillary splint and a fully customized lower active device.

The first goal in designing this appliance was to maximize the intraoral space for the tongue. Using the thin splint on the maxillary arch and a movable shield coming off the lower arch in front of the anterior upper teeth to hold the mandible forward accomplished this. It turned out that the anterior shield feature provides many different health benefits.

The first goal was maximizing tongue space; the second goal being comfort. I knew one of the ways to make the appliances as comfortable as possible was to allow freedom of movement without putting torque on the teeth. Having the main body of the appliance snapping on the lower teeth allows lateral and some up-and-down movement of

the jaw without over-stressing the upper or lower teeth. The main force on teeth would be the ‘’pull-back” from repositioning of the mandible, anchored against the upper anterior teeth. The thin upper cushion spreads the force around dental arch.

The next insight I had was to reduce nasal resistance, a major issue in sleep disordered breathing that was not being addressed in any appliance. I have experienced the benefit of the Cottle maneuver and wanted to find a way to add this benefit to an oral appliance design. The nasal valve, with internal and external components, is the place where 2/3‘s of the resistance to air flow occurs in the entire respiratory tree.1 The Cottle maneuver2 is a test that ENT physicians perform by stretching the cheeks laterally, opening the nasal valve to determine if there is improvement in nasal airflow. Through experimenting on myself, a perfect guinea pig, I found that it was possible to mimic the Cottle maneuver intraorally with extensions that stretched the nasiolabial fold. We had the perfect location for the nasal dilators, coming off the anterior upper shield.

The nasal dilators open the nasal valve all night long as well as 27–28% improvement in the middle region of the nasal airway bilaterally with the use of a non-surgical, intra-oral, nasal dilation appliance.

When it came time to obtain a FDA 510K clearance the ENT division of the FDA was brought in and I was asked to show that the nasal dilation was actually caused by the appliance feature. We studied OASYS with and without the nasal dilators in the ENT division of the FDA and our design was officially cleared as a nasal dilator. This is why the OASYS is the only dental device for treating sleep apnea that is cleared in two separate categories, by the dental division of the FDA as a mandibular repositioner to treat sleep apnea and by the ENT division to treat nasal resistance. These findings were published in Sleep and Breathing.3 With the research that showed exercises such as playing the didgeridoo or doing in-

COMBINATIONtherapy

Patient presenting with tongue rolled up in back of the throat representing poor tongue and throat function.

The tongue in good functional position locked into the palate will move forward with mandibular repositioning.

The tongue guides extending off the lower base of the OASYS.

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tensive speech therapy exercises improve the airway and lower the AHI, I started to study tongue anatomy and position in my patients to see if I could understand what was going on and could improve upon the tongue and throat function. These observations revealed many patients with enlarged tongues extending over the occlusal surface, many with scallops on the borders and some that retracted into the back of the throat with the tip of the tongue adjacent to the second molars.

To influence tongue position, I first tried adding a shelf on the entire anterior third of the lower base of the appliance, hoping to lift the tongue up to the palate. What I found was that on many patients that made things worse; instead of the tongue going up over the shelf it would sit behind and be pushed further back into the throat. This is similar to what I observe in patients with large mandibular tori; instead of the tori making the tongue go up to the palate, it would rest behind the tori, pushing the tongue further back into the airway.

I next tried extensions coming off the lower base to guide the tongue up to the palate.

This also made the patient’s swallowing more dynamic, establishing a better tongue posture and swallowing pattern.

Instead of discomfort, we have found that the vast majority of patients don’t feel the buttons at all, but they do enjoy the positive

effects. I am also working with speech pathologists on a developing a new field I call “Dental Speech Therapy.”

The last benefit is lip closure. Chronic mouth breathing produces a short upper lip; to close the lips together the mentalis muscle pushes the lower lip up to meet the short upper lip. In sleep, the muscle relaxes and lip competency is lost, increasing oral breathing at the expense of nasal breathing. I questioned whether the upper shield would make the situation worse. Fortunately I found that the upper shield had a significant advantage in that even if the lips part, the shield fills the space, sealing the mouth as if the lips are closed. Over time, as recently confirmed by physical therapist Mario Rocabado, the connective tissue in the upper lip stretches and improves lip closure.

In summary the OASYS Oral/Nasal Airway System is a simple, comfortable oral appliance that provides multiple actions addressing the upper airway from the tip of the nose to the back of the throat.

References 1.

Partitioning of respiratory flow resistance in man. B. G. Ferris JR., J. Mead , L. H. Opie Journal of Applied Physiology Published 1 July 1964 Vol. 19 no. 4, 653-658 DOI: 2.

Effects of the Cottle’s maneuver on the nasal valve as assessed by acoustic rhinometry. Tikanto J, Pirilä T. 3.

Effect of an intra-oral nasal dilation appliance on 3-D nasal airway morphology in adults. G. Dave Singh & Mark Abramson.

Sleep Breath DOI 10.1007/s11325-007-0130-1

Dr. Mark Abramson is a TMJ and Sleep Apnea dentist, serving patients in Redwood City, in the San Francisco Bay Area. He supports the treatment of the Physician, Sleep Specialist and Sleep Disorders Laboratories. He attended the University of Maryland School of Dentistry where he graduated in 1975.

Upon graduation he came to California to do a general practice residence at the Palo Alto Veterans Hospital. Shortly after completion of his residency training, he limited his dental practice to treating the special needs of those suffering with TMJ and headache and facial pain.

Dr. Abramson is a Diplomat, American Academy of Orofacial Pain, Diplomat, Academy of Pain Management, Diplomat, American Academy of Dental Sleep Medicine, and a Fellow, American Academy of Craniofacial Pain Management. He is a member of the American Dental Association, California Dental Association, American Academy of Dental Sleep Medicine where he is on the program committee, American Academy of Craiofacial Pain Management, Cranial Academy and his dental license is extended to include acupuncture treatment.

Dr. Abramson developed the O2 OASYS Oral/Nasal Airway System™ and in 2004 received FDA approval for this device to go to market.

Dr. Abramson teaches courses in the fields of TMJ /TMD Cranial Facial Pain Management, and Dental Sleep Medicine and Mindfulness Based Stress Reduction. He directs Stanford University’s Mindfulness Based Stress Reduction Clinic and teaches ongoing classes on this program through Stanford University School of Medicine. Dr. Abramson is a staff physician at Stanford University Hospital.

PRODUCTspotlight

The AirHead P

atients can see at a glance the problems caused by obstructive sleep apnea using the Airhead™ Obstructive Sleep Apnea Patient Demonstration Model, created and manufactured exclusively by TMD Technologies. This patented device quickly and easily demonstrates not only how sleep apnea affects breathing, but also how the use of an appliance can correct the problem. Use the included simulated intraoral appliance and the benefits become crystal clear.

The Airhead™ model and functional display together stand 12” tall, with small foot-

print that makes it easy to keep the device within reach; it also includes a hook for wall-mounting. Hand-cast in high-quality polyurethane resin, the head disc rotates 90º to show a supine position. In addition to the simulated intraoral appliance, the model comes with a display stand that even sports a clear holder for your business card. For more information, visit www.airheadosa.com.

“Every once in a great while, a product comes along that is elegantly simple and wonderfully productive. The Airhead patient demonstration model has become an integral part of my dental sleep medicine practice. Patients often say they never understood airway collapse until they saw the Airhead model in action. They love it. I love it.” – Dr. Robert Rogers, Pittsburgh, PA

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PRACTICALtips

Enhancing Retention of a 3-D Printed Nylon Sleep Apnea Appliance

by John Viviano, DDS, DABDSM

B

y now most everyone practicing Sleep Dentistry has seen or handled a CAD-CAM sleep apnea appliance. Fabricated by a 3-D printer using a laser sintering process, these appliances are made of type 12 organic polyamide, better known as nylon; a material we simply donâ&#x20AC;&#x2122;t have much experience with in Dentistry. Despite the initial impression of seeming fragile due to minimal size and thickness, this material has demonstrated itself to be much more resilient then dental materials we have used to date. I have been surprised regarding how much we can grind away at this material when dealing with bite issues or patient comfort, without compromising the appliance.

This nylon polymer has a very unique set of characteristics; rigid at a thickness of 2mm or more and flexible at a thickness of 1mm or less, it can be safely reduced to a thickness of 0.5mm and down to 0.2mm for a small surface area such as a cusp tip, without compromising appliance integrity. It is even possible to pierce through the material over a very small area without affecting the structural integrity of the device, but an uninformed patient may interpret this hole as a defect so this is best avoided or if necessary explained to the patient before performing the adjustment. This nylon polymer is quite remarkable to say the least. However, tightening these nylon appliances in cases of poor retention post fabrication has been an issue.

Attempts have been made to describe tightening the appliance by heating it with a flameless torch, pinching it between your fingers and placing it in cold water to maintain the pinched shape. I have tried this technique

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on several occasions obtaining only a marginal increase in retention and never enough to actually remedy the problem. That being said, I am told that with practice this technique will allow one to reshape the appliance around a new crown! Perhaps that is possible, but clearly not easily accomplished by the faintof-heart. After all, we are talking about an expensive appliance that melts when you apply enough heat to it! So, this technique may work better for some than for others, depending on your intestinal fortitude!

Another suggestion has been to add some restorative resin to the buccal of the teeth lacking retention, creating more of an undercut. However, this poses the problem of extra cost, extra chair time and the liability of resin that can (and will) fall off. Finally, remakes are costly to everyone: the manufacturer, the patient and to the wet fingered dentist. Any technique facilitating the EASY increase of post fabrication appliance reten-

PRACTICALtips

tion would be a very valuable addition to your Sleep Disorders Dentistry protocols. So here goes…

Lionel Dwyer, of Orthodent Dental Laboratory in Oshawa, Ontario has come up with the best solution to date. Actually, it turns out that slightly revised, the technique used to increase retention in plastic retainers can also be used to increase retention in nylon sleep apnea appliances. However, before one puts a hot iron on an expensive nylon appliance I would suggest reading the protocol described below and trying the technique on a practice appliance.

This protocol utilizes the following tools: Hilliard Undercut Enhancing Thermoplier, Round Acrylic Burs, Miltex Calipers, Flameless Butane Torch, Digital Thermometer.

What we are talking about is increasing the depth that the nylon protrudes into the interproximal undercuts; thus increasing appliance retention. The Hilliard Undercut Enhancer Thermoplier can be used to do this in the same manner it is used on plastic retainers.

Step 1

Initial Set-up of Thermoplier: Adjust the amount of adaptation the plier will provide by adjusting the hex-screw, which allows you to set exactly how far the plier will push into the nylon. (Once you are set up with a practice appliance you can engage the Thermopliers as described in the text below and set the hex–screw appropriately. Once set, the same depth should work fine from case to case.)

Step 2

Step 1: Adjust Thermoplier

Visually survey the lingual and buccal of the teeth lacking retention on the patient’s model, and decide which interproximal areas may be exploited to increase retention. Mark these areas with a pencil inside the appliance.

The goal will be to have the marked protrusions extend further into the interproximal undercuts thus increasing retention. In the pictures to the left you will see the target retention enhancement areas marked in pencil inside the appliance and at the corresponding spot on the out side of the appliance.

John Viviano, DDS, D ABDSM, obtained his credentials from the University of Toronto in 1983. His clinic is limited to providing conservative therapy for Sleep Disordered Breathing and Sleep Bruxism, commonly referred to as snoring, sleep apnea and tooth grinding. A member of various sleep organizations, he is a Credentialed Diplomate of the American Board of Dental Sleep Medicine, and has lectured internationally, conducted original research and authored articles on the management of Sleep-Disordered Breathing and the use of Acoustic Reflection to evaluate the upper airway.

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PRACTICALtips

Step 3

Step 4: Heat the wedge-tip of the plier

Step 3

If the interproximal area you will be enhancing is too thick, you will need to reduce this thickness with an acrylic bur on the outside of the appliance. Using the pencil mark from the previous step as a guide, reduce the nylon thickness first with a 4mm round acrylic bur, and then with a 2mm round acrylic bur to demarcate exactly where you will be placing the beak of the thermoplier to enhance retention. Avoid grinding the material thinner than 0.5mm. Calipers come in handy to ensure you don’t do this. In the picture to the right you see the reduction of material by round acrylic bur in the target areas.

Please keep in mind that it is not always necessary to reduce the nylon thickness, or to reduce it to 0.5mm. On your practice model you can experiment with using the thermopliers at various levels of thickness to determine what works best in your hands.

Reduction is only necessary to allow the thermopliers to engage the area properly and should be done sparingly.

Step 4

Heat the wedge-tip of the plier for 4-5 seconds with a flameless butane torch. This should bring the temperature up to around 30°C. A digital thermometer can be used to confirm that you have not overheated the plier. This nylon has a thermoforming temperature of 50-60°C. However, I find that the plier works well at about 30°C, which can be achieved with about 5 seconds of heating.

Remember, too cool and the nylon will not be modified, too hot and you may burn right through the nylon. Melting temperature for this nylon is north of 172°C (341°F); as the temperature you will be working with is far less, there should be no concern. You may be tempted to wing it but an inexpensive

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Step 5

digital thermometer can help alleviate any concern regarding irreversibly damaging the appliance, at least while you are becoming accustomed to this technique.

Step 5

Squeeze the handles of the plier together to enhance the undercut ginigival to the contact point. You may have to enhance a number of undercuts but I suggest enhancing one at a time while you are becoming accustomed to this procedure. This material returns to a non-deformable state when the temperature normalizes which takes about 4-5 seconds after applying the pliers to the nylon.

So, first squeeze the pliers, you can observe the undercut area being enhanced inside the appliance as you squeeze, then hold the pliers in place for about 4-5 seconds while the nylon cools, then remove the pliers and check the appliance either on the patients teeth or model to determine if the retention is sufficient. If not, repeat the process at another interproximal area until retention is satisfactory. Of course, if the appliance ends up too tight, a light adjustment with an acrylic bur to the nylon that protrudes into the undercuts should relieve this.

Although these appliances are very accurately manufactured, there are a variety of reasons you may end up with insufficient retention. So far, this is the best technique I have seen to help resolve retention issues without the trouble and expense of a remake. Unlike the “heat and pinch” technique that has not worked for me after several attempts, the “plier trick” worked the very first time and every time since! For those cases not requiring reduction with a round acrylic bur it is has been particularly rewarding to be able to kick the retention up a notch in literally 1-2 minutes. Thanks Lionel.

Reprinted from www.SleepScholar.com

LEGALledger

Morning

Repositioning

Is This Therapy the Standard of Care?

by Ken Berley, DDS, JD, DABDSM

S

tandard of Care (SOC) is defined as: “What a reasonable and prudent practitioner would do in the same or similar circumstances.” SOC is a curious concept among medical professionals. Frequently, I discover that health care professionals do not understand that Standard of Care is a legal concept and is ultimately determined by a jury. Most professionals firmly believe that they determine the standard of care for their profession. To some degree that is correct. Health Care professionals (experts) present medical opinions in a court of law outlining what, in their opinion, should have been done to prevent a particular injury. Then a jury determines the standard to be applied. Until a jury rules on a particular therapy, no legal precedent or standard exists.

That begs the question; “Is the fabrication of a Morning Repositioning Device (MRD), within the SOC for the practice of Dental Sleep Medicine?” If not, should it be? Obviously, at this point no jury has determined that the inclusion of an MRD is legally mandatory, however, wouldn’t a reasonable and prudent practitioner fabricate an MRD to minimize the effects of mandibular advancement? In preparation for this article, I took an informal poll and found that only 52% of those polled routinely fabricated a MRD. When asked why MRDs were not routinely fabricated, I received excuses ranging from: not necessary; no reimbursement; don’t work, and patients don’t want another device.

In Dental side effects of mandibular advancement appliances – a 2-year follow-up.

J Orofac Orthop. 2008 Nov;69(6):437-47. doi: 10.1007/s00056-008-0811-9. Epub 2008 Nov 11. It was concluded that: Clinically small but statistically significant dental side DentalSleepPractice.com

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LEGALledger effects predominantly affecting the incisors’ inclination occur after long-term wear of a Mandibular Advancement appliance. Overbite was highly significantly reduced (p = 0.006). The maxillary front teeth showed significant palatal tipping and those in the mandible significant labial tipping. Therefore, it is my opinion that tooth movement secondary to Mandibular Advancement may be the most significant long term complication of Oral Appliance Therapy. Therefore, from a risk management prospective, it is my legal opinion that a Morning Repositioning Device should routinely be employed to minimize this complication.

I have been unable to find any research which confirms that the use of a MRD will ultimately prevent tooth movement secondary to OSA, however clinically I see the results every day. Using a maxillary hard night-guard

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

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type MRD with an anterior ramp that is fabricated in centric occlusion will assist the patient in recapturing his/her centric bite each morning. The anterior ramp is inclined at a 60 degree angle and guides the mandible back into centric while simultaneously repositioning the lower anterior teeth into their original position. The hard acrylic night-guard will reposition the maxillary teeth functioning like a retainer or invisalign tray.

With the addition of a MRD to our treatment protocol, the issue of reimbursement always comes up. YES, I file for medical reimbursement for this device. I use the TMJ code S8262. This code is used whenever we are repositioning the mandible. I am well aware that we have traditionally used this code for TMJ therapy, however the code is not limited to that diagnosis. S8262 adequately describes the therapeutic function of a Morning Repositioning Device. Truthfully, only 50% +/- of my patients have medical benefits for S8262, however we routinely provide a MRD when treating OSA. If the patient does not have benefits for S8262, I use thermoplastic or one of the commercially available in-office techniques.

When filing medical insurance for S8262 with E0486 for OAT, you must be prepared to provide a letter of medical necessity for the S8262. I have included my letter for consideration.

To Whom It May Concern; This is in response to your request for information regarding the treatment proposed for your insured, Mr. XXXX. Mr. XXXXX has been diagnosed with Obstructive Sleep Apnea, OSA 327.23. Mr. XXXX has been referred to our office by his sleep physician for treatment of his OSA with a Mandibular Advancement Device, MAD E0486. The treatment will include 2 different types of devices. The E0486 is a custom fabricated FDA approved Mandibular Advancement Device that will open his airway at night by advancing his mandible thereby controlling his OSA. By holding the mandible forward the airway is expanded and airflow is improved. The MAD maintains a patent airway which improves breathing and reduces OSA. Without this treatment Mr.XXXXX’s ____________ (co-morbid medical condition) can deteriorate which represents a major threat to his health.

The second device is S8262, a Mandibular Orthopedic Repositioning Device. This device

LEGALledger is used in the morning to reposition the condyles in the glenoid fossa and to correct any dental misalignment that may have occurred during the night while wearing the MAD, E0486. The device is used to prevent TMD and tooth movement secondary to MAD therapy. Without this S8262 device, Mr. XXXXX could likely suffer TMJ Dysfunction and permanent displacement of the mandible in an anterior position, thereby causing permanent bite changes and necessitating orthodontic or surgical correction. This orthotic is medically necessary for the successful treatment of Mr. XXXXX’s OSA with a mandibular advancement device. The patient will be required to use both of these devices the remainder of his life unless surgical intervention or other treatment is instituted.

If you have any questions please feel free to contact me.

Sincerely, Ken Berley, DDS, JD, DABDSM

By including MRD in my treatment protocol, I have effectively increased my compensation for the treatment of OSA while simultaneously reducing the possibility of secondary tooth movement. This therapy provides a safeguard and an argument that you were proactively attempting to prevent any tooth movement. Coupled with a comprehensive informed consent, a MRD will effectively minimize your liability and would likely prevent any Malpractice action secondary to tooth movement.

In Conclusion: Is MRD the Standard of Care for Oral Appliance Therapy? No; not at this time. However, in my professional legal opinion, with the research that we currently have, it is the only SMART way to treat OSA. If you are not already routinely constructing MRD’s for your patients with OSA, please help me make this the Standard of Care by adding this procedure to your protocol.

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SLEEPhumor

...The Lighter Side of Sleep Apnea

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