Dental Sleep Practice Summer 2019 by MedMark, LLC

Population Sleep Health:

Dentists Providing Solutions

by Drs. Michael S. Simmons and Colin M. Shapiro

Introducing ProSomnus [PH] ®

Thank you

e the First for Helping Creat -style Device Precision Herbst

SUMMER 2019 | dentalsleeppractice.com

PLUS

Continuing Education: Dental Sleep Medicine:

A Case Study of a TMD Patient with a 24-year History of Refractory Epilepsy Entirely Controlled with a MAD

Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Daniel E. Taché, DMD

PATIENT SCREENING l BITE REGISTRATION l ORAL APPLIANCE SELECTION / FABRICATION

THE POWER OF A GOOD NIGHT’S SLEEP Empower yourself to help your patients Dentists trust Great Lakes. And have trusted Great Lakes for sleep screening devices, appliances, and technical support for over 25 years. Whether you are new to sleep medicine or a veteran, we have the solutions to help your patient’s sleep disordered breathing.

Nonin WristOx2® 3150

The George Gauge™

MediByte®

Panthera D-SAD™

dreamTAP™ Rhea®

Hard Telescopic Herbst®*

Rest assured, we’re here to help. Learn more and get in touch with a sleep expert. 800.828.7626 l greatlakessleep.com

Great Lakes Orthodontics is now Great Lakes Dental Technologies

* Herbst is a registered trademark of Dentaurum, Inc.

SMLP663Rev040119

INTRODUCTION

Is this Medicine, Dentistry, or Does it Matter?

o you make ‘doctor-level’ decisions in your practice of providing oral appliances to treat disease? Do you think it matters which disease? Which insurance company covers the patient?

Medicine is heavily siloed – broken down by specialties who become incredibly talented in narrow areas of human health and disease. Prevention and other physiology-spanning approaches find little attention paid. Dentistry, limited to only a few specialties, has many more generalists charged with whole-person health. Dr. L.D. Pankey taught us, as one of his key principles, to take the entire patient, not just their teeth, into account when providing optimum health care. Yet traditionally, when dentists have looked beyond the oral cavity, limitations are imposed by dentists, physicians, and governing bodies to keep a solid wall between practicing ‘dentistry’ and practicing ‘medicine.’ Enter ‘Dental Sleep Medicine,’ an increasingly outdated term as clinical experience and scientific research has shown how airway problems affect far more than sleep. Medicine, with one tool to treat the second-most commonly diagnosed disorder of sleep, is acknowledging that mechanically improving airway patency is not going to be achieved with PAP alone. Uncomfortably for their practice model, physicians have to prescribe not to widget purveyors with limited training, but to highly educated peers with their own ideas for how to help patients. Solutions involving the oral cavity are not off-the-shelf ‘fittings,’ but fully customized medical devices capable of causing harm as well as therapy. Insurance companies, in control of nearly every medical decision made in this country, are struggling with this issue. Most understand that decisions must be made, treatment does not always follow a linear path, and there is human variation in response that requires doctors to manage. (Read Dr. Tache’s case report in this issue for a superb example.) Many allow dentists to enroll as

providers, which opens doors for more people to be treated, while others refuse and insist patients navigate the uncertain territory of ‘out of network providers.’ CMS has recently hardened its position that dentists are considered merely device providers, with zero benefits for examination, imaging, or follow-up appointments, requiring a surety bond Steve Carstensen, DDS from licensed dentists like they do a med- Diplomate, American Board of ical supply store in the shopping center. Dental Sleep Medicine CMS, hampered by a lack of clarity in their own published rules, provides different answers depending on who you speak with and has not shown us an unambiguous statement one way or the other, leaving dentists to follow disparate interpretations. Meanwhile, there are tens of thousands of dentists charged with screening their patients for SRBD. Millions of people are learning about the importance of breathing well during sleep. Solutions involving the With a fast-growing consumer oral cavity are not offsleep technology industry capable of easily guiding any interested party the-shelf ‘fittings,’ but along the path to a more open airfully customized medical way during sleep, addressing simply observed symptoms like snoring and devices capable of causing daytime sleepiness may become a harm as well as therapy. drugstore issue. As these waves crash upon the bulkheads of traditionally siloed medical practice and the limitations imposed by licensure and insurance companies, it soon won’t matter much who lays claim to patients breathing poorly during the night. People will find solutions that work for their best interests, not to keep things the way they’re done now. Dentistry and Medicine must join forces to make sure the truly needy patients are identified and offered treatment. Otherwise, the professionals will be pushed aside. DentalSleepPractice.com

CONTENTS

Population Sleep Health… Dentists Providing Solutions

Thank you

the First for Helping Create Device t-style Precision Herbs

Expert View

by Drs. Michael S. Simmons and Colin M. Shapiro Challenging our profession to truly make a difference.

Cover Story

Intoducing ProSomnus [PH] by Mark T. Murphy, DDS, FAGD, and Len Liptak, MBA, CEO for ProSomnus Sleep Technologies One of DSM’s early devices redesigned for better with input from dentists.

Continuing Education

Technology

Time to Connect with a Virtual Doctor! by Jagdeep Bijwadia, MD, MBA, DABSM, and Kyle Miko, CRT/CSE Solutions so your patients don’t have to wait.

64 2 DSP | Summer 2019

Dental Sleep Medicine: A Case Study of a TMD Patient with a 24-year History of Refractory Epilepsy Entirely Controlled with a Mandibular Advancement Device by Daniel E. Taché, DMD What can you and your team learn from this dentist’s story?

2 CE CREDITS

Legal Ledger

Home Sleep Apnea Testing and Dental Sleep Medicine by Jayme R. Matchinski, Esq. It depends on your state and your doctors.

With ProSomnus Dentists can provide better OSA therapy for all patients.

CAPPED SCREWS FOR COMFORT

Visit ProSomnus

Booth #301

at the AADSM!

ANTERIOR AND POSTERIOR COMFORT BUMPS

UPPER GOLD SCREW FOR ORIENTATION

METAL-FREE HOOKS FOR ELASTICS

Introducing ProSomnus® [PH]. The first and only Precision Herbst-style Sleep Device. • A More Comfortable Choice. 18% smaller. 83% less lingual thickness. 13% lower profile. • An Easy Choice. Biocompatible, engineered hygienic material. Symmetrical titration, designed for fewer side effects. • A More Efficient Choice. 7.0mm titration range. Easy Replacement. Best in class 3+2 year warranty. Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness. Visit ProSomnus.com or call 844 537 5337 for a free starter kit.

CLEARED

844 537 5337 ProSomnus.com Leader in Precision OAT®

PATENTED

E0486 VERIFIED

CONTENTS

Publisher’s Perspective

Taking a Stand for Success by Lisa Moler, Founder/CEO, MedMark Media

Team Focus

ADA, Airway and the Team by Glennine Varga, AAS, RDA, CTA The ADA wants you to help every patient.

Product Spotlight

Pushing the Boundaries of Dental Sleep Practice Management by Jeff Burton, Founder/CEO, Lyon Dental Sleep Services Results come from thinking of innovative ways to help.

Product Spotlight

TAP with AccuTherm Trays: Fits the first time, every time…without a handpiece This company is always improving how we can help our patients.

Practice Management

The Importance of TMD for the DSM Practice by Rose Nierman, CEO Nierman Practice Management You can’t treat one without the other.

Marketing

11 Steps to Branding Your Sleep Practice for Success by Marc Fowler Success depends on people knowing who you are.

Survey Results

Physicians and Medical Insurance There are four players around the sleep apnea table.

Summer 2019

Laser Focus

Hot Glass Tip Diode Frenectomies Are Not Laser Frenectomies by Peter Vitruk, PhD, MInstP, CPhys You need the right tool for the job if you want to do it best.

Product Spotlight

A Success Story by Béatrice Robichaud Love nylon devices? They’re better than ever.

Book Review

Book Review by Pat Mc Bride, MA, RDA, CCSH A resource for you and your team.

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

Nutrition

“An Apple A Day” by Julia Worrall, RN This old saying is based on facts!

Comorbidities

Sleep and the Growing and Going Problem by Warren Schlott, DDS Medical problems must be part of the discussion.

Seek and Sleep

DSP Jumble

VP, Sales & Business Development Mark Finkelstein | mark@medmarkmedia.com National Account Manager Celeste Scarfi-Tellez | celeste@medmarkmedia.com Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Front Office Administrator Melissa Minnick | melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.DentalSleepPractice.com

Behavioral Therapy

Five Reasons to Consider Taping Your Mouth at Night

by Paul A. Henny, DDS Keys for helping patients to understand this valuable strategy.

4 DSP | Summer 2019

Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2019. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

Custom Milled Herbst® § Three Year Warranty

§ Smooth Diamond Finish

§ Medicare E0486 Verified

§ Thinner Design

§ Superior Strength

§ Maximum Tongue Space

With our new high precision 5 Axis milling machines, we can create an extremely accurate, crystal clear and impressively strong device. We utilize the newest CAD/CAM digital software and highly trained technicians to ensure an accurate fit and silky smooth finish to your milled devices. The new milled line of OSA devices are currently available in the Adjustable Herbst® and DynaFlex Dorsal® and includes a 3 Year Warranty. The Adjustable Herbst also has Medicare E0486 Verification for reimbursement.

PUBLISHER’Sperspective

Taking a Stand for Success

t a recent seminar on growing business practices, one particularly meaningful session started with the speaker asking people to stand if their business has lasted 1 to 5 years. After that group sat down, next, the 5- to 10-year group was asked to rise. When recognizing people in the 10- to 15-year category, I looked around to see very few in that category standing in this large room. I was surprised and humbled, and also very proud that after 1½ decades, I was still standing — both literally and figuratively.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Summer 2019

With the ever-changing business climate we are currently living in, it is often difficult to keep track of all of the details needed to keep your business in the public eye while staying laser-focused on expansion and growth. While general dentists and specialists alike need to concentrate on all of the technology and techniques that lead to better patient care, you also must remember, and already may be painfully aware, of the vital importance of understanding how to keep your business side booming. From social media to networking with colleagues, to methods for hiring and retaining employees who will have your back and your practice’s best interests in their minds, both entrepreneurs and dentists have to find a work-life balance between our personal and business lives. In our upcoming issues, my column will offer tips on how to be a successful entrepreneur while being a caring business owner and running a profitable business! As a woman entrepreneur, I understand the frustrations and triumphs of tackling the world of business with all of its complexities and the competition of others who are also chasing success. It’s a massively competitive world we are living in! This issue’s articles address cutting-edge topics and treatment. Our cover story, by Dr. Mark T. Murphy and Len Liptak, illustrates the benefits of the ProSomnus [PH], a precision, next-generation OAT device that uses more comfortable, stronger, and more biocompatible materials and enables optimized device designs. See the spirit of collaboration that led to the development of this FDA cleared, PDAC-approved sleep device. In our CE article, Dr. Daniel E. Taché shares his case report of a patient who suffered from epileptic seizures, severe jaw pain upon awakening,

teeth grinding, and SRBD. An intraoral airway device changed her life. The author sums up, “there is a bi-directional relationship between pediatric sleep problems and epilepsy, that an unaddressed SRBD is a risk factor for refractory pediatric epilepsy.” Read his discussion of this innovative treatment when anti-epileptic drugs were insufficient. Our Expert View, provided by Drs. Michael S. Simmons and Colin M. Shapiro, shows how a health profession-guided process to recognizing SRBD will help identify the more complex sleep disorder cases and direct patients to the expert sleep physicians/ expert sleep dentists in a timely fashion. They recognize that in the case of sleep health, dentists can play a big role in solutions for their patients. They quote Albert Einstein as saying, “We cannot solve our problems with the same level of thinking that created them.” We hope that through articles such as these, we shine a light on new concepts and new solutions for this “brave new world” of sleep dentistry. Through my future columns, I hope to connect with you not just as dental specialists, but business people and entrepreneurs. At Dental Sleep Practice, we care about your stress AND success, and the often challenging and even painful journey to achieving your goals. After 15 years, I’m still standing – proud of the hard work that it took to get here, proud of my amazing, unwavering team that constantly has my back, and looking forward to all of the exhilaration of embracing and conquering business speed bumps and hurdles, while still learning with every step. I’m still standing. My goal is for you all to stand with me in the coming years, with our fierce entrepreneurial spirits — tackling life, propelling us upward, and pushing us forward to unlimited success in both your business and personal aspirations!

COVERstory

Introducing ProSomnus [PH] ®

A Commitment to Better OSA Therapy for All Patients

by Mark T. Murphy, DDS, FAGD, Lead Faculty for Clinical Education at ProSomnus Sleep Technologies and Len Liptak, MBA, CEO for ProSomnus Sleep Technologies

ot long ago a few dozen leading Dental Sleep Medicine clinicians convened to address a deceptively simple question: “Is it possible to engineer a better Herbst-style OAT device?”

8 DSP | Summer 2019

Actually, the conversation commenced with a robust discussion on the feasibility of changing the coding for Medicare devices. The group opined that the current coding limited OAT device selection and diverged from AADSM guidance documents in certain areas. The ability to select from a variety of devices was seen as important for delivering effective and efficient OSA therapy to patients. Several clinical and industry leaders from many organizations have made tremendous efforts to change the coding – to no avail. If better OSA therapy for all patients is the objective, the reality of the current Medicare coding made it necessary to consider developing a next generation Herbst-style

COVERstory device. With a collective understanding, the group pivoted to the question of defining a better Herbst-style device.

Opportunities for a Better Herbststyle Device

The group advised that patients needed a Herbst-style device that was more comfortable. Currently available Herbst-style devices did an adequate job alleviating OSA. However, many patients had difficulty adapting to them. OSA is a life-long disease. Most patients were prescribed OAT after failing CPAP. It was important to have a Herbst-style device that patients could tolerate all night, every night. This guidance on comfort also extended to the desire to reduce the risk of side effects, such as the lower anterior crowding associated with traditional Herbststyle devices. Importantly, this group of expert dentists explained that a Herbst-style device needed to be easy to use. Medicare patients are more likely to have compromised dentition. Considering the age and capabilities of general Medicare-eligible patients, the group listed several characteristics: The ideal device would be easy to keep clean. It should be easy to insert and remove. It should be more biocompatible. And easy to adjust, among other things. The group explained that they wanted a device that was efficient to prescribe, deliver and manage. Clinical efficiency was advanced as a tactic for offsetting reimbursement concerns. Medicare reimbursement rates were already low and had declined recently in some jurisdictions. They were not expected to increase any time soon. The count of Medicare beneficiaries is forecasted to increase by 30 million by 2030. Additionally, some private insurance companies have started adopting PDAC coding. Device breakage, slippage, discomfort, delamination and adjustments meant inefficiencies in the form of unplanned appointments. Moreover, Herbst-style devices were challenging to repair, expensive to replace if lost or damaged, and often meant the patient was without a device or placed in a temporary device during the repair or replacement process. “The use of Herbst-style devices in Dentistry has been utilized in the dental world for many years. There has not been any change in the design of this appliance and that has

left many of us in the field with few alternatives for treatment. The ProSomnus Herbststyle device development has taken the recommendations and frustrations of dentists and created a design that now respects the patient’s comfort, the doctor’s desires and the overall improvement in compliance and functionality that is ex“Never doubt that a pected in a superior product. Kudos small group of to ProSomnus for the vision to make things better for the doctors and thoughtful, committed our patients that trust us so well.” – ‘clinicians and innoDavid B. Schwartz, DDS, D-ABDSM This is the spirit of collaboration vators’ can change the that gave birth to the First Precision ‘dental sleep’ world; Herbst-style OAT Device, the Pro® Somnus [PH]. The ProSomnus [PH] indeed, it’s the only is an FDA cleared, PDAC approved thing that ever has.” sleep device. This exceptional group of dentists wanted a better OAT ex– Adapted quote from Margaret Mead perience for their Medicare patients and other patients who might benefit from a Herbst-style device. But how, within the PDAC constraints, does one engineer a better Herbst-style Device? The ProSomnus precision OAT platform would form the foundation for the ProSomnus [PH] Precision Herbst-style device. The ProSomnus precision platform is a unique confluence of forward engineering, precision

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

DentalSleepPractice.com

COVERstory the subtleties of patient phenotypes while minimizing variances in the production of a Medical Device. Precision means using materials that are stronger, more biocompatible, and enable optimized device designs. Precision means simulating titrations when designing devices to ensure symmetry and design harmony throughout treatment. In sum, precision means the opportunity for dentists to create a better patient and practice experience. “I think the ProSomnus [PH] is the best Herbst-style appliance on the market to date. The ProSomnus platform enables a very slim profile which is a plus, also the added bumper feature helps patients so they won’t feel the screw mechanism. My patients love the smaller, smoother, new design and protection of their cheeks. Patients can easily advance the nut with the tool provided. I love providing my patients with a better oral appliance option. Makes my job easier too, which is a win-win.”– Erika Mason, DDS, D-ABDSM, D-ACSDD

Occlusal view

manufacturing and material science that enables the Company to create innovative OAT devices with meaningful advantages. It is the same precision OAT platform that enables the ProSomnus [IA] and [CA] devices that have been used to successfully treat tens of thousands of patients by many leading Dental Sleep Medicine clinicians, reinforced by clinical studies demonstrating efficacy, effectiveness, adherence and mitigation of side effects like tooth movement.

A More Comfortable Choice

Patients and clinicians have noted that, “It is smaller.” This is not an accident. It is by design. The ProSomnus [PH] device has 18% less overall volume (fig. 1), on average. It also has 83% less lingual splint thickness (fig. 2), for the purpose of optimizing protrusiveness and comfort while minimizing the risk of side effects. Patients have also noted that it is, “Much more comfortable.” Again, this is by design. ProSomnus [PH] has specific design characteristics that are intended to make the device more comfortable. The ProSomnus [PH] features comfort bumps that are intended

Developing ProSomnus [PH]

Precision means confidence that the prescription is faithfully and accurately represented in the device design such that the clinician will spend more time treating the patient and less time compensating for the device (i.e. making up for handmade human error). Precision means responsiveness to

Lateral view

18% Smaller – Overall Volume Comparison Chart

Figure 1

10 DSP | Summer 2019

83% Less Lingual Thickness – Lingual Flange Thickness Comparison Chart

Figure 2

COVERstory to protect the lip commissures and cheeks. Comfort bumps come standard with the ProSomnus [PH]. The comfort bumps can be easily removed, for example, if there are concerns of interference with the coronoid process. ProSomnus [PH] also has a 13% lower profile (fig. 3) in the anterior screw aspect, than traditional Herbst-style devices. The attachment screws are capped for comfort and hygiene. “We had become accustomed to our patients complaining as soon as they were shown a Herbst-style design. This all changed when the ProSomnus [PH] became available, as the transparent design along with the shielded hinges are much less off-putting to our patients.” – B. Kent Smith, DDS, D-ABDSM, D-ASBA

13% Lower Profile – Lower Anterior Screw Aspect Thickness Comparison Chart

Figure 3

An Easy Choice

Patients who have switched from a traditional Herbst remarked that it is, “Way easier to use.” The ProSomnus [PH] offers several features that are designed to make the device easier for patients and team members. The upper arch features a gold color screw for orientation during insertion. The hex nut titration screw is designed to be more definite, minimizing slippage. The ProSomnus [PH] features metal-free hooks for elastics. “ProSomnus listened and has created unique changes to the traditional Herbst appliance. One of which is the creation of ‘comfort bumps’. Now the most common complaint from patients using a Herbst-style appliance has been successfully addressed!” – Kenneth A. Mogell, DMD, D-ABDSM

A More Efficient Choice

The ProSomnus [PH] features the most flexible titration range of any Herbst-style device. It comes with a standard 7.0mm titration range, 6.0mm of forward range and 1.0mm of backward range. And as with all ProSomnus devices, additional titration arches can be ordered if more advancement range is needed. The ProSomnus [PH] features a unique, best in class, 3+2 Year Warranty. The [PH] comes standard with a 3-year warranty, plus a free-of-charge option to add 2 more years for Medicare patients. Additionally, the ProSomnus [PH] is designed to be easy to repair and replace. Herbst-style arms are easy to replace if needed. The device can be precisely

Capped screws

Anterior and posterior comfort bumps

replicated from existing records if there is a need for a replacement. The patient can be converted to a ProSomnus [IA] or [CA] device from existing records if there is a need, or if the patient simply desires a backup device. Like so many leading Dental Sleep Medicine clinicians, the commitment to better OSA therapy compels ProSomnus Sleep Technologies to continuously advance. Identify. Analyze. Innovate. That is the basic mantra of continuous improvement. Though ProSomnus manufactures precision OAT devices, it isn’t about the device. It is about treating the patient with OSA. It is about developing and manufacturing devices that can make it easier for the dental team, in small but meaningful ways, to create meaningful and successful treatment experiences. It is a commitment and passion, supported by technical excellence and expert clinical insights, that led to the creation of the ProSomnus [PH] Precision Herbst-style Sleep and Snore Device – a new option for helping clinicians deliver the best possible OSA therapy for their patients.

Left: Upper gold screw for orientation; hex nut adjustment. Right: Metal-free hooks for elastics

DentalSleepPractice.com

EXPERT view

Population Sleep Health… Dentists Providing Solutions by Drs. Michael S. Simmons and Colin M. Shapiro

opulation level sleep disorders and sleep deprivation were reported by the Institute of Medicine in 2006 to be an “enormous unmet public health need”1. Sleep, like nutrition and physical activity, is a critical determinant of health and well-being1. Now, a dozen years after this landmark report, there is strong indication of further decline in healthy sleep in our communities. Studies indicate inadequate sleep has increased in industrialized populations to between 33-45% of adults2,3,4 and poor sleep quality starts as early as 3 years old, due to issues such as screen time5. Population level unhealthy sleep has resulted in substantial economic and health costs approaching $600 billion/year in the U.S. alone as of 20176 and this figure does not include the childhood age group.

The iconic sleep textbook’s opening chapter7 states “from today’s vantage point, the greatest challenge for the future is the cost-effective expansion of sleep medicine to provide benefit to the increasing number of patients in society.” While healthy sleep, along with healthy diet and exercise contribute to longevity and quality of life, the general lack of education about healthy sleep continues to be prevalent and most concerning in healthcare providers8,9. Uninformed health providers contribute to poor guidance for the public, who may view snoring as normal, unrestful sleep as unavoidable, and self-imposed sleep deprivation as a badge of honor. Population based health problems require population-based solutions! One pragmatic answer to resolving population-based sleep health problems is to identify resources and remove barriers that limit access to care. In the case of sleep health there are two main issues at hand: sleep disorders affecting about 1/3 of the population and unhealthy

12 DSP | Summer 2019

sleep behaviors affecting a further 1/3 of the population. Many people have both issues. Conservatively 100+ million are affected by unhealthy sleep in the U.S and >12 million in Canada. Identifying sleep disorders is important and the vast majority with sleep disorders fall into three readily diagnosable ICSD-3 categories10: sleep related breathing disorders (SRBD), insomnia. and circadian rhythm disorders. Identifying poor sleep behaviors is also typically not too challenging and usually respond to sleep hygiene coaching and cognitive behavioral therapy. The rub in all this is the counterproductive bottleneck to diagnosis and the lack of primary care in addressing these simple and readily identifiable presentations of unhealthy sleep. Early diagnosis and multiple portals of entry into the healthcare system are one obvious answer. The other is population-based education and practice of best sleep health behaviors. Sleep physicians, numbering about 6,00011 hail from a variety of primary specialties and should act in the capacity of quarterbacks, like the cardiologist specialist in cardiovascular health, to address the more complex and challenging presentations. The approximate 850,000 U.S. physicians are typically untrained in sleep disorders12 and are often overwhelmed with their current practice of problem-based care, hard-pressed to add sleep disorders assessment. Pediatricians, otolarngologists and mental health providers, who frequently see sleep disorder presentations, could add about 15,000 doctors to the 6,000 sleep physicians but would still leave an enormous healthcare gap with less than 25,000 to manage well over 100,000,000 potential patients. This is where dentists and others in primary care can significantly help to close the gap. Dentists, like family physicians and, in some jurisdictions, nurse practitioners,

With ProSomnus

Dentists have the opportunity to avoid side effects. (1)

E0486 VERIFIED

PROSOMNUS [IA] ITERATIVE ADVANCEMENT

No statistical change in tooth position(1)

Assessment of Potential Tooth Movement and Bite Changes With a Hard-Acrylic Sleep Appliance: A 2-Year Clinical Study. Journal of Dental Sleep Medicine: Vol. 6, No.2 2019

PROSOMNUS [CA] CONTINUOUS ADVANCEMENT

PROSOMNUS [PH] PRECISION HERBST-STYLE

Side effects are a top 5 reason MD’s do not prescribe OAT(2)

2.5x to 5.0x less porosity for bio-gunk(3)

(1)

Oral Appliance Therapy Awareness and Perceptions Survey, by Sree Roy. Sleep Review. January 2016

(2)

CLEARED

Say No to Bio-Gunk!, by Dr. Michel Gelb, DDS. Dental Sleep Magazine, Insider: VMarch 2018

(3 )

PATENTED

Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness. Visit ProSomnus.com or call 844 537 5337 for a free starter kit.

844 537 5337 ProSomnus.com Leader in Precision OAT®

EXPERT view physician assistants and chiropractors, are primary health care providers, licensed to diagnose and work unsupervised. In the U.S., dentists number just over 190,000. So if 1/3 of all dentists could engage in providing primary sleep healthcare, it would more than triple the currently available primary sleep health providers. Other primary healthcare providers could also supplement this workforce to increase the number of patients diagnosed with sleep disorders. This all sounds fine until the process of engaging patients into care is explored. The current bottleneck is in diagnosing SRBD, insomnia or circadian problems as if it is some difficult diagnostic sequence or process. On the contrary, diagnosing the majority of these sleep disorders is most often quite simple with a concerted sleep focused history and, if indicated, sleep testing,13 which can be mostly done at home and interpreted remotely by a boarded sleep physician. While screening is sometimes used as a wide net to catch potential sleep disorders, positive results merely indicate the need for a sleep history, associated exam, and potential sleep studies that are required for diagnosis. Some professionals identify sleep disorders as a “medical

The consequences of “mis-diagnosis” are logarithmically shy in population health impact when compared to the currently existing “missed diagnosis.”

Michael Simmons, DMD, MSc, MPH, FAAOP, D-ABDSM, D-ABOP, maintains two California dental practices focusing on Sleep Disorders and Orofacial Pain and has been a longtime Lecturer at UCLA’s dental and medical schools. He’s earned a MSc in sleep medicine from the University of Sydney and an MPH at UCLA with focus on sleep health. Dr. Simmons has authored and published peer reviewed scientific papers and book chapters on Sleep Disorders and Orofacial Pain. Dr. Simmons is well recognized in the dental and sleep health care provider communities, has served on various state and national sleep society boards as well as being active in his local and state dental societies, advocating for increased dentists’ involvement in sleep health. Colin Shapiro, BSc, MBBCh, PhD MRCPsych FRCP(C) trained in medicine in South Africa. As a student, he published in Science and in Experientia Journals. He completed medicine and went on to do a PhD in sleep physiology. He’s investigated the use of sleep recordings for diagnostic purposes in psychiatry, and chronobiology in psychiatry and pharmacology. He became the youngest full professor in the department of psychiatry at the University of Toronto, founded the British Sleep Society and was founding president of the International Neuropsychiatry Association. He has published over a dozen booklets for family physicians, dentists and patients. (www.sleepontario.com) Currently, he is very much involved in the public health aspects of sleep.

14 DSP | Summer 2019

problem” outside the scope of practice of dentistry and others opine family physicians would not be interested. The consequences of “mis-diagnosis” are logarithmically shy in population health impact when compared to the currently existing “missed diagnosis.” In this context it should be noted that there was a time when only cardiologists measured blood pressure and while many others now treat cardiovascular disease, cardiologists have become substantially busier. Diagnostic pathways are rapidly changing with the development of technology, using tools that will be equivalent to and in some ways more appropriate than sleep studies in lab. In her 2017 annual report, the President of the American Academy of Sleep Medicine noted11 that patients “are monitoring and tracking their own sleep in ways we never could have imagined 20 years ago”. Rather than have patients self-diagnose, health professional should be recruited, trained and engaged. The obvious first answer is dentists, who may diagnose and treat other life threatening “medical” disorders such as oral cancer, nicotine addiction, bulimia, and obesity. Dental professionals are highly trained in the anatomy and physiology of the oral cavity and associated structures, preventive and health maintenance therapies, and are an underutilized systemic healthcare provider. While dentists may be pigeonholed to periodontal disease, “TMJ,” and tooth decay, they see more patients annually in health and disease than physicians who are problem-focused. In the quest for public health solutions to unhealthy sleep, putting the diagnostic territorialism to rest is a worthy compromise. Training of doctor-level healthcare providers such as dentists initially, and then others, will help fill the gap in sleep health. Enabling patients to use quality devices for home recordings dispensed by a dentist, nurse, psychologist or family physician and interpreted by a sleep physician would be infinitely more desirable than allowing patients to self-diagnose and treat using a smart phone app presenting unvalidated data about their sleep. Moreover, the health profession guided process will help identify the more complex sleep disorder cases and get them to the expert sleep physicians / expert sleep dentists in a timely fashion. Currently these sleep experts are overwhelmed with the simple cases and lack availability to focus on the challeng-

EXPERT view ing cases that only they can manage. This is akin to limiting diagnosis and primary care of all patients with hypertension and high cholesterol to cardiologists. Clearly, we would witness in short time a drop off in care for the more challenging cardiomyopathies. So, in this brave new world, the dentists and other members of the health professions are taught best practices in providing initial diagnosis of SRBD, insomnia and circadian problems along with provision of first line therapy as primary care providers for the simple cases, forwarding the more complex cases to the specialists. The diagnostic and treatment paradigms are developed, tested

1/3

More than

of the population have insufficient sleep

and upon proof of concept, these paradigms of care are duly instituted. Reimbursement to dentists is through medical billing, similar to other medical/dental crossover health issues such as headache and TMJ disorders that may or may not have medical coverage or have costs below high medical deductibles. When the value of care is recognized by patients, they often pay independent of insurance coverage. This is no different than cosmetic dental and medical care where patients pay out of pocket. In any event, insurance carriers must not discriminate against any healthcare provider diagnosing and delivering primary sleep health care simply to cost contain. Einstein said “We cannot solve our problems with the same level of thinking that created them”. It’s time to recognize unhealthy sleep not just as a problem for the individual but rather as a public health problem. In the case of sleep health, dentists can definitely play a big part in the solutions. 1.

10.

11. 12.

13.

Institute of Medicine (US) Committee on Sleep Medicine and Research. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. (Colten HR, Altevogt BM, eds. Washington (DC): National Academies Press; 2006. http://www. ncbi.nlm.nih.gov/books/NBK19960/. Adams RJ, Appleton SL, Taylor AW, et al. Sleep health of Australian adults in 2016: results of the 2016 Sleep Health Foundation national survey. Sleep Health. 2017;3(1):35-42. doi:10.1016/j.sleh.2016.11.005 St-Onge M-P, Grandner MA, Brown D, et al. Sleep Duration and Quality: Impact on Lifestyle Behaviors and Cardiometabolic Health: A Scientific Statement From the American Heart Association. Circulation. 2016;134(18):e367-e386. Kronholm E, Partonen T, Härmä M, et al. Prevalence of insomnia-related symptoms continues to increase in the Finnish working-age population. J Sleep Res. 2016;25(4):454-457. doi:10.1111/jsr.12398 Genuneit J, Brockmann PE, Schlarb AA, Rothenbacher D. Media consumption and sleep quality in early childhood: results from the Ulm SPATZ Health Study. Sleep Medicine. 2018;45:710. doi:10.1016/j.sleep.2017.10.013 Hillman D, Mitchell S, Streatfeild J, Burns C, Bruck D, Pezzullo L. The economic cost of inadequate sleep. Sleep. doi:10.1093/ sleep/zsy083 Pelayo R, Dement W. The history of Sleep Physiology and Medicine Chapter 1 in Principles and Practice of Sleep Medicine 6th Edition 2016 Mindell JA, Bartle A, et al. Sleep education in medical school curriculum: a glimpse across countries. Sleep Med. 2011;12(9):928-931. Simmons MS, Pullinger A. Education in sleep disorders in US dental schools’ DDS programs. Sleep Breath. 2012;16(2):383392. doi:10.1007/s11325-011-0507-z American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine ; 2014 https://aasm.org/resources/pdf/rosen-president-report-2017.pdf Mukherjee S, Patel SR, Kales SN, et al. An Official American Thoracic Society Statement: The Importance of Healthy Sleep. Recommendations and Future Priorities. Am J Respir Crit Care Med. 2015;191(12):1450-1458. Magalang UJ, Johns JN, et al Home sleep apnea testing: comparison of manual and automated scoring across international sleep centers. Sleep Breath. 2018 Sep 10. doi: 10.1007/ s11325-018-1715-6.

DentalSleepPractice.com

TEAMfocus

ADA, Airway and the Team by Glennine Varga, AAS, RDA, CTA

n October of 2017 the American Dental Association released a policy statement that impacts every dental office in the US. This policy statement was the first step toward identifying the role of the dentist and dental team regarding sleep-related breathing disorder treatment. Let’s break down the policy statement and identify how we can integrate these concepts into practice and promote this very important message from the ADA. First, become familiar with this policy statement: https://www.ada.org/en/publications/ ada-news/2017-archive/october/sleeprelated-breathing-disorder-treatment-out lined-in-new-policy Read it multiple times, post it in your office and share on social media. For the first time in history, the ADA is getting involved with advising dentists to screen for sleep-related breathing. Take advantage of this endorsement with your patients. Patients will ask, “Why are you asking about snoring or why are you assessing my airway?” Part of your answer can be, “Because it’s our role to do so.” According to the ADA House of Delegates of 2017, dentists are the only health care provider with the knowledge and expertise to provide oral appliance therapy. Since dentists and dental team are often the first to identify symptoms and discuss medical and dental history with the patient, The Council on Dental Practice developed the policy. The policy is intended to help dentists on the front lines help their patients through proper recognition and treatment. Here is our first task as team! Identify what sleep-related breathing questions are currently on your medical and dental history that can be used to have a discussion with your patients. Specifically, snoring, waking up choking or gasping, cardiovascular, respiratory, dental and other systematic diseases should be identified with patients. It may be necessary to customize your history intake to include airway compromised questions. I’m a true believer the

16 DSP | Summer 2019

more we get to know our patients, the better we can communicate, educate and influence them to make educated decisions toward therapy. Take the time for this critical step and let your patients do the talking. It is imperative to link signs, symptoms and risk factors as many patients are clueless how sleep-related breathing could contribute to overall health and wellness. Now that we understand our profession plays a major role in screening and treating sleep related breathing disorders, what exactly is this policy directing us to do? Perhaps the most important directive in the policy addresses children. Screening through history and clinical examination may identify signs and symptoms of deficient growth and development or other risk factors that may lead to airway issues. You might have heard Margaret Mead’s quote about “Small groups of committed citizens can change the world.” There are eight task forces of dedicated dentists, physicians, and medical professionals working right now to provide guidance in this area for the dental profession, including you and your office team, so stay tuned! In the meantime, look for mouth breathing, tongue-tie (attachment), thumb or finger sucking, noisy breathers, chronic runny noses, large tonsils, earaches, high palatal vault, crowded or no spacing in primary dentition, overbite, overjet, retrognathic jaw, speech impairment, hyperactivity, developmental delay, poor concentration and bed wedding as a start. Create two different patient intake questionnaires – one for adults and one for children. ADA’s policy statement says if risk is determined, intervention through medical or dental referral or treatment may be appropriate to help treat the disorder and/ or develop an optimal physiologic airway and breathing pattern. In the dental office I was in we did not have a great office to refer these kids, so we became the source. We took continuing education to learn how to treat these types of patients. As team, it is vital to take the extra step to learn these con-

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TEAMfocus cepts or find a provider in your community that can. If you can’t travel with your doctor to courses, ask if they will support online learning for you. There are some wonderful programs that focus on children’s airway like the ADA’s CE courses, The Healthy Start System, MyoResearch training or Rondeau Seminars which all provide online courses for convenience. Next, the policy says oral appliance therapy is an appropriate treatment for mild to moderate sleep apnea, and for severe sleep apnea when CPAP is not tolerated by the patient. As team we can help by making Many patients are sure to administer protocol and get copies of baseline sleep test reports as part of our clueless how sleep- room set up before diagnosed patients are related breathing seen. Use this baseline report to confirm and severity and whether there contributes to overall diagnosis is the right detailed information to be health and wellness. used for the patient’s medical insurance claims. Most policies base benefit on severity of OSA. The policy will state what other documentation is needed to prove medical necessity. We can also create literature for our physician referral entities that outline the referral relationship. Make sure and work with your dentist to solidify your communication. The policy statement also indicates obtaining a written or electronic prescription order for an adult patient with OSA. We team can help facilitate this by gathering physician contact information from our patients and faxing requests for written prescriptions. You can continue to nurture the relationship no different from any other referring entity. Once patients commit to oral appliance therapy, the policy statement says dentists

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

18 DSP | Summer 2019

should obtain appropriate patient consent for treatment that reviews the treatment plan, all available options, and potential side effects of using oral appliances. You see, most of what the ADA has in the policy, team can facilitate. A signed informed consent from your patient is vital – make sure and get a great one, preferably from an attorney. Give your patients time to read it and have them sign with a witness from the team. Ideally, doctors explain what’s in the informed consent to the patient. Team can make sure it gets done and patients have a copy to take home. As patients progress with oral appliance therapy the policy states dentists should monitor and adjust the appliance for treatment efficacy as needed, or at least annually. Let’s help with this process by checking into your dental practice management system to find a way to flag your sleep patients to evaluate annually. If you have a DSM specific system, get training on how to set this up so you can monitor annual visits and financial responsibility discussions. The policy indicates that dentists should consider surgical procedures as a secondary treatment when CPAP or oral appliances are inadequate or not tolerated. In selected cases surgical intervention may be considered as a primary treatment. Schedule time as a team, order in some yummy local food and do some research. Find physicians you would like to reach out to establish a referring relationship. Decide as a team which offices you would like to approach and role play what you would say if you called or visited their practices. Make it happen – the more your office is out in the community the more referrals you will get. The last point the policy statement reflects is that dentists treating sleep-related breathing disorders should continually update their knowledge and training of dental sleep medicine with related continuing education. If your office allows for team CE, ask to go with your doctors – the more education you can get the better. I know when I’m leading a group of learners in a sleep/ airway course, I love it when team are in the audience! Focus on educating your patients, they will appreciate it when the time comes to make a decision. At the end of the day, it’s the patient’s decision – let’s help them make a good one!

PRODUCTspotlight

Pushing the Boundaries of Dental Sleep Practice Management by Jeff Burton, Founder/CEO, Lyon Dental Sleep Services

he dental sleep industry has certainly made great strides in recent years. More dentists are pursuing education and more patients are expressing interest. Through my company, Lyon Dental, I’ve been fortunate enough to interact with hundreds of passionate dentists who are focused on implementing dental sleep. As much as I am enthusiastic about the potential of our field, I am equally concerned about the barriers that still exist. I am surprised at how many practices continue to struggle with practice management fundamentals including workflow, documentation and billing. In addition, most dental practices don’t fully embrace the shift to medical when they approach these functions. What does this mean? Well, your workflow for dental sleep is unlike anything you do in your general dental practice because you are treating a medical condition. There is a heavy burden to produce internal and external supporting

20 DSP | Summer 2019

documentation so that you can comply with complex medical policies. Billing for oral appliance therapy is perhaps the most difficult piece of the puzzle and without the right resources and process in place, there is little chance at seeing any reimbursement from medical insurance. So what if there was a better solution focused on overcoming these barriers? I’ve spent the better part of the last 5 years trying to figure it out. As a registered nurse with experience working for a major health plan and a large physician group, I approached this problem from a different perspective. We must think about ALL of the key external stakeholders here – referring physicians, insurance companies, and patients. How could we develop a system that would meet their demands AND make it easy for a dental practice to manage cases? The answer was a comprehensive practice management platform that pushed the boundaries of dental sleep medicine. MD FusionTM is a next-generation, cloud-based software that we believe will be a game changer for the industry. It brings the technical elements of dental sleep together with the fundamentals of practice management for an end-to-end solution that breeds efficiency. It was designed with an intuitive workflow to guide practices without the need for extensive training. The strongest feature are the built-in templates that will ensure higher compliance with the documentation requirements from payers and communication demands of physicians. Top it off with the most robust medical billing module available to dentists with fully integrated billing services and you’ve got a system that truly supports the missing requirements our field has desperately needed. Our mission is to help dentists see the value in embracing a slightly different model that is further aligned with a medical approach in order to better meet the needs of our stakeholders.

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PRODUCTspotlight

TAP with AccuTherm Trays: Fits the first time, every time…without a handpiece

n the history of dental appliances and restorations, there has always been one issue that never seems to go away – Fit. No matter how great the restoration or appliance is, if it doesn’t fit, it doesn’t work. Since we work in microns, the task is difficult.

It’s a simple solution that insures every appliance fits the first time.

Over the years, analog impression materials have evolved and proven to be very accurate, as long as you follow the instructions perfectly and don’t have a gagger or highsaliva patient. Of course, full arch impressions required for mandibular advancement devices are the most difficult. Digital impressions (scans) have some unique positive attributes and can also yield excellent results, but the software must stitch together images, which requires an algorithm to interpolate the photos and create virtual surfaces. This process can result in small inaccuracies. Since full arch scans require the most interpolations, they are the most prone to fit issues.

Introducing AccuTherm™

The latest invention from Airway Management eliminates fit issues. Here’s the lowdown: AMI has created a new tray disc with a thin layer of our ThermAcryl® heat activated thermoplastic factory laminated to a PET-G (Polycarbonate) shell. The trays are precisely adapted to the models with air pressure in the lab. Then the final fit, and any adjustment required, are done by simply warming the fit-

22 DSP | Summer 2019

ted tray in hot water. No handpiece needed. Once the ThermAcryl® material becomes clear and soft, insertion into the patients mouth yields a custom, perfect fit with great retention. If any adjustments need to be made, all you need is hot water! The total thickness of the tray is about 3.1 mm, making AccuTherm™ one of the thinnest trays in the industry. It is very comfortable and small in the mouth and is 20% thinner than our popular triple laminate (TL) trays! The process does NOT require any CAD/ CAM equipment investment, no milling machines, no 3D printers, no expensive models, no chairside digital scanners. Nothing new to learn. It’s a simple solution that insures every appliance fits the first time. The simplicity will inspire confidence when using oral appliances for your staff and patients. As if that wasn’t enough, consider these other cool features: • New crowns: no worries. Just heat the trays in hot water and refit. • You can add a small amount of additional ThermAcryl as needed • Double thick Polycarbonate shells have been proven to be very durable over the last 10 years • The Snap Fit with AccuTherm makes this tray a superior choice for retention. • It flexes over undercuts and sticks the seating • 100% custom fit in the chair – With no handpiece. • Train the Staff: Use www.TAP.wiki, the clinical educational site for all things TAP. AccuTherm™ will be available as a tray option for all TAP appliances beginning May 2019. Contact Airway Management at 866264-7667 or email contact AMI@amisleep. com for more information.

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PRACTICEmanagement

The Importance of TMD for the DSM Practice by Rose Nierman, CEO Nierman Practice Management

“O

nce you see it, you can’t unsee it,” was a common and powerful assertion at a recent seminar on TMD for the Dental Sleep Medicine Practitioner. Classic oral signs such as abfractions, tongue scalloping, facial pain, bruxism, and micrognathia that dentists come across every day all correlate with airway issues.

Mounting evidence and studies also Many medical show a strong correlation between OSA and insurance carriers TMD, strongly reinforcing the need for advanced TMD and orofacial pain treatment reimburse for skills and education. According to recent studies, excessive daytime sleepiness is more medically necessary frequent among masticatory myofascial pain TMD treatment. patients.1 It is also more likely that patients with low-frequency sleep bruxism may present with painful temporomandibular joint disorder (TMD). Given that there is a relationship between sleep bruxism and SBD, TMD may be diagnosed in patients with SDB. In a study, Cunali et al.2 evaluated 87 adult patients with mild to moderate OSA and found 52% had TMD. The OPPERA cohort and case-control studies3 found that signs and symptoms of OSA were associated with occurrence of TMD. In the cohort study, a high probability of OSA was associated with increased incidence of first-onset TMD. Moreover, a high probability of OSA was associated with increase of chronic TMD. It’s clear that DSM practitioners should acquire the skills to proactively assess, diagnose and treat TMD and orofacial pain. Becoming a well-rounded DSM practitioner with orofacial pain skill sets differentiates your practice and allows you to provide the best quality care for your patients. Most dentists managing OSA strive to be well-informed about the TM joint and delve into any orofacial pain or TMD issues. Nierman Practice Management’s Sleep Apnea Questionnaire and Exam forms incorporate a TMD and orofacial screening to identify, document, and review any underlying pain condition or TM joint disorder. Why it’s essential to study advanced TMD and orofacial pain diagnosis and treatment: 1. If any TMJ complications arise after a patient begins oral appliance therapy, immediately managing symptoms prevents more advanced issues. 2. If not the dentist, who? The dental professional is the primary care provider for TM joint dysfunction, capable of significantly improving the quality of life and overall health of patients. 3. The American Academy of Dental Sleep Medicine (AADSM) Practice Parameters for OSA puts the responsibility clearly on dentists to

24 DSP | Summer 2019

recognize and treat TMD problems in sleep apnea patients during follow-up exams. The American Dental Association Policy Statement on Dentists Treating Sleep Related Breathing Disorders mandates that dentists providing therapy be adept at managing side effects. 4. Oral appliances for OSA may not be considered medically necessary in patients who have significant TMJ issues. Some medical insurers have recently added this caveat to medical policies, so it has become even more necessary to document and potentially stabilize any TMD issues before oral appliance therapy for OSA. 5. Many medical insurance carriers reimburse patients for medically necessary TMD treatment. With medical insurance coverage, more patients can move forward with vital medically necessary treatment. The fact that most U.S. states now mandate TMD coverage in their benchmark health care plans increases reimbursement success for TMJ disorders. When it comes down to it: the goal is to get the Positive Airway Pressure (PAP) intolerant patient treated for OSA/SDB as quickly as possible. The sooner every differential diagnosis is documented and treatment is prioritized, the better for the patient and the dental practice. From a recordkeeping and medicolegal standpoint, it’s essential to document all head and neck findings during the OSA screening. When a patient presents with facial pain or jaw clicking, the skills to make a differential diagnosis and triage treatment are integral to successful treatment. Determining if the diagnosis is an articular disc disorder, joint arthritis, contracture of the muscles of mastication, or a laxity of the TM joint ligaments is vital to moving forward with your treatment for both pain and OSA.

PRACTICEmanagement From a reimbursement standpoint, when patients require both TMD treatment and OSA appliance therapy, medical claims are typically billed individually; thus, the medical billing process is triaged along with treatment. Nierman Practice Management offers cross-coding certifications for dental offices to bill procedures such as trauma to the oral cavity, bone grafts, implants (placement & removal), OSA, TMD, frenectomies, biopsies, incision & drainage, functional appliances and medically necessary orthodontics

Rose Nierman is an early pioneer in the field of cross-coding and medical billing in dentistry. Rose continues her mission of helping get dentists paid and implement dental sleep medicine and TMD services. A major innovator in dental sleep medicine and medical billing software, Rose developed dental sleep medicine & TMD questionnaire and exam forms which have become the standard in thousands of dental practices and are used by insurers to established medical necessity. Nierman Practice Management’s crosscoding seminars educate thousands of dental practitioners on Rose’s established cross-coding and medical billing processes. Contact Nierman Practice Management at contactus@dentalwriter.com or 1-800-879-6468.

(and the list goes on). Billing medical often ensures you are not leaving any money on the table and patients are more likely to receive medically necessary treatment. What if there was one thing that could make the difference in your practice? There is! Train your team in Dental Sleep Medicine, TMD and medical billing in dentistry. Differentiate your practice from others and make it a point to connect with physicians who encounter facial pain and sleep patients. Master OSA appliance therapy, increase your TMD knowledge and your team’s medical billing skills to take your practice to the next level. 1.

Balasubramaniam R, Klasser GD, Cistulli PA, Lavigne GJ. The link between sleep bruxism, sleep-disordered breathing and temporomandibular disorders: an evidence-based review. Journal of Dental Sleep Medicine. 2014. Cunali PA, Almeida FR, Santos CD, et al. Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy. J Orofac Pain 2009. Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA Cohort. J Dent Res 2013.

www.dentalsleeppractice.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter CONNECT with us on social media

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26 DSP | Summer 2019

TECHNOLOGY

Time to Connect with a Virtual Doctor! by Jagdeep Bijwadia, MD, MBA, DABSM, and Kyle Miko, CRT/CSE

elemedicine is becoming an increasingly important part of healthcare. The Department of Health and Human Services estimated that in 2018, 60% of all health care facilities were using some form of telemedicine.

Trends like increasing commercial payer acceptance of telemedicine, continuing technological advances, and growth of consumerism in healthcare all indicate that telemedicine offerings will expand significantly in the years to come. Patients increasingly expect real-time access to healthcare in the same way they receive other commercially available services. You probably expect the same thing for your personal health care – it’s time to provide it for your patients! American Academy of Sleep Medicine has stated that it supports efforts to expand telemedicine and is committed to increasing the adoption of this technology to improve patient access. Their recent position paper details the key features, standards, and processes for a sleep specialist. Dental Sleep medicine as a field is uniquely positioned to take advantage of the new telehealth technology. Obstructive sleep apnea is a significant health issue with an estimated 80% of patients remaining undiagnosed. Dentists are uniquely positioned to identify patients who are at risk for obstructive sleep apnea but there are some significant barriers that prevent patients from getting to oral appliance therapy in an efficient and cost-effective manner. The lack of availability of sleep physicians in some areas, the high cost, requirement for numerous visits, and time involved in the diagnosis and treatment of obstructive sleep apnea remain challenging. Although predicting individual response remains a challenge, oral appliances are an extremely effective, patientpreferred option for the treatment of sleep apnea, often as a first line option. The typical patient who is identified at risk for sleep apnea by a dentist is referred to a sleep physician’s office for consultation and diagnosis. Appointments can often take several days or even weeks for that initial consult. Further delays occur with the sleep testing process, especially if polysomnography is pursued. A trip back to the physician for discussion adds another layer of complexity before a prescription for treatment can be completed. Communication back to the dentist can be sub-optimal given the disparate communication platforms that dentists and physicians use. Patients are lost at various steps on this pathway and vital opportunities to impact health are missed. As patients go through the complex pathway, costs escalate with every step, and the chances that the patient will ‘give up’ increase. Telemedicine can potentially help address many of the barriers that face dentists and physicians in getting patients to oral appliance treatment. Using a telemedicine platform allows a patient who is identified as at risk for obstructive sleep apnea to be diagnosed and treated efficiently. Technology and services exist today that allow a patient identified as at high risk for obstructive sleep apnea to be scheduled for a virtual consult right at the dentist’s check out desk. Consultation is completed either while

the patient is in the dentist’s office or within just a few days in the comfort of the patient’s own home via a secure, HIPAA compliant, web-based platform. Prior to the consult, they register and fill out some medical information in preparation for the visit. The visit itself is carried out on any mobile device and is a real-time video link. The physician or nurse practitioner performing the consult can review the medical notes and document their visit. The video interface allows the clinician to do a comprehensive review and answer any of the patient’s questions as well as educate them about diagnostic and treatment options. A brief physical exam can be performed for findings like facial structural abnormalities, retrognathia, and Mallampati scores. If the patient is physically in the dental office, vital signs and even electronic stethoscopes may be used for more complex patients. At the end of the visit, ordering a home sleep test allows a diagnosis to proceed in a cost-effective manner for most patients, unless there are reasons to pursue more in-depth testing. Several companies perform home sleep tests by mailing the equipment to the patient and having it returned in a prepaid package. Once interpreted by board-certified sleep physicians, the study can be reviewed by the consulting clinician and an order for an oral appliance can be generated to the referring dentist. There are several important advantages of using the telemedicine and home sleep testing model. From a dentist’s perspective, it makes the referral process efficient since the scheduling for the telemedicine visit can be done right at the time of checkout. ConsultaDentalSleepPractice.com

TECHNOLOGY

74% About

of patients in the U.S. would use telehealth services.4

tions and sleep study reports should be available to review as they are completed on the telemedicine platform. This allows for easy communication between the dentist and the physician. Documentation for claims submission is immediately accessible online rather than having to track down various pieces of information from other offices. Many dentists currently collaborate with home testing companies that generate sleep test reports and who even provide prescriptions for patients that the physician group has never interacted with. Using telemedicine and collaborating with physicians allows accurate diagnosis and importantly the ability to consider sleep disorders other than OSA that are often responsible for the patient’s symptoms. For the physician, telemedicine expands their reach and allows them to selectively schedule the more complex patients requiring additional care to their offices. While at home telemedicine consultation is not yet reimbursed by insurers, telemedicine visits completed in a clinical setting like a dental office are usually covered by the patient’s insurer. Home sleep testing is also covered benefit when sleep apnea is clinically suspected and the study has been ordered after appropriate clinical evaluation. For the patients, telemedicine reduces the time spent traveling back and forth to various

Dr. Jagdeep Bijwadia is the founder and CEO of SleepMedRx. He is board certified in Internal Medicine, Pulmonary Medicine and Sleep Medicine. Prior to starting his own practice in Minnesota, he served as Attending Physician at HealthPartners Medical Group (HPMG), where he was the Department Head and Director of the Sleep Medicine Center. He currently holds a faculty position as Assistant Professor in the Department of Pulmonary Critical Care and Sleep Medicine at the University of Minnesota. He has been named top doc by the Minneapolis magazine as well as US News and World Report. He is a past president of the Minnesota Sleep Society. Kyle Miko, CRT/CSE, is co-founder of VirtuOx Inc. and currently serves as the company’s Chief Operating Officer. VirtuOx is a Channel Solutions and Technology Company specializing in diagnostic products and services in the respiratory, sleep disordered breathing, neurology and cardiology sector of the modern healthcare system. Kyle has played an integral role in all aspects of VirtuOx business development, including medical device sales and creation of the following home diagnostics: overnight pulse oximetry, home sleep apnea testing, home insomnia testing and home cardiac arrhythmia monitoring.

offices and sleep centers and is also much less expensive. Patients who are not located close to a sleep specialist can have increased access to high-quality specialty consultations. As you choose a telemedicine partner, look for a group that specializes in sleep medicine and that is experienced and understands the nuances of dental sleep medicine. Ask questions about the telemedicine platform, making sure it is HIPAA secure and that it allows you access to your patient’s data. Seamless integration with home sleep testing with a company that in the patient’s insurance network is helpful so that the dentist does not have to coordinate and have the expense of two separate services and also minimizes the patients out of pocket expenses. The ability to provide follow up consultations on request and offer advice after efficacy testing allows the partnership to work across the continuum of care. Availability of physician appointments, state licensure, turnaround times for home testing and cost are all important considerations. Telemedicine may be an ideal option for dentists who are starting out in the field of dental sleep and would like to get patients they identify on to treatment efficiently and safely. It is also a useful option for dentists who have established sleep practice but whose patients travel long distances or want a less expensive but high-quality path to treatment. It is important to note that Medicare does not currently allow reimbursement for oral appliances with telemedicine consultations and still requires a face to face visit. Telemedicine is ideal for dentist-physician collaboration but in the future may have many other applications in dental sleep medicine. Experienced clinicians mentoring and even supervising other dentists in real time is likely to help increase availability and expertise in dental sleep, allowing patients increased access to care. Other advances in technology and new uses will doubtless surface in the next years making this an exciting time to be in the field. 1.

2. 3.

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Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation. Report to Congress: E-health and telemedicine. Washington, DC: Department of Health and Human Services, August 12, 2016 Telehealth. Tuckson RV, Edmunds M, Hodgkins ML. N Engl J Med. 2017 Oct 19;377(16):1585-1592. American Academy of Sleep Medicine (AASM) Position Paper for the Use of Telemedicine for the Diagnosis and Treatment of Sleep Disorders. Singh J, Badr MS, Diebert W, Epstein L, Hwang D, Karres V, Khosla S, Mims KN, Shamim-Uzzaman A, Kirsch D, Heald JL, McCann K. J Clin Sleep Med. 2015 Oct 15;11(10):1187-98 http://americas.nttdata.com/Industries/Industries/Healthcare/~/media/Documents/White-Papers/Trends-in-Telehealth-White-Paper.pdf;

MARKETING

11 STEPS

to Branding Your Sleep Practice for Success

by Marc Fowler

aving worked with dozens of dental practices, from those who have just started treating sleep patients to some of the most productive sleep practices in the country, it has become evident that in order to maximize the growth of a dental sleep practice, you must have a brand identity for sleep which is independent of your general dental practice brand.

In order to maximize the growth of a dental sleep practice, you must have a brand identity for sleep that is independent of your general dental practice brand.

Your goal is to position yourself as the expert in airway and sleep breathing issues in the minds of prospective patients. Webster defines an expert as one with special skill or knowledge representing mastery of a particular subject. The subjects of dentistry and sleep apnea treatment don’t naturally go together. When a prospective patient sees sleep apnea listed in your services section next to teeth whitening, dental implants and crowns, they will have trouble making the connection. In other words, simply adding a page or two about sleep to your general dental practice website does little to position you as the expert to prospective sleep patients. Bullseye Media has developed the following checklist of steps necessary to establish an effective brand identity and differentiate your sleep practice.

An example of a dedicated sleep website

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Sleep Practice Branding Checklist 1. Select a name for your sleep practice. The practice name should not contain the word “dental.” When a patient sees “dental sleep” they’re most likely thinking sedation. 2. Purchase a website domain name. Ensure the domain is easy to spell and remember. The shorter the better. Ideally, choose the .com version of your new sleep practice name. 3. Design a new logo. The logo needs to be professionally designed and visually pleasing. The graphics should communicate the message that you help patients breathe and sleep better. 4. Establish a separate phone number. You’ll need a separate phone number to claim online directory listings for your sleep practice. It will also enable your staff to answer incoming calls using the name of your sleep practice. 5. Build a dedicated sleep website. When a prospective patient lands on your website they’re forming an impression of your practice within seconds. A well-executed sleep website will educate, establish authority and ultimately convert website visitors into scheduled sleep consultations. 6. Create and optimize a Google Business Listing for the new entity. Critical elements include your sleep practice name, website address and dedicated phone number. Optimize your listing by uploading your logo along with some professional photos of you, your team and the office. 7. List your practice on the leading online directories. If you aren’t sure which ones to focus on first, do a few Google searches incorporating your city name into the search term and see which directories show up consistently. The key directories will differ by city and keyword search terms. 8. Start a Facebook page for the new practice. Utilize your new logo and colors for

MARKETING brand consistency. Have someone in your office post to it weekly. Important details to include in the About section: a link to your new sleep website, your office address, your phone number, and an overview of your sleep practice. 9. Collect patient reviews for your sleep practice. Google, Yelp and Facebook reviews are the most important. Reviews from sleep patients will resonate with potential sleep patients as well as provide valuable keywords to help Google associate your practice with sleep related searches. 10. Create a YouTube channel. YouTube is the third most visited website in the U.S. and the second largest search engine after Google. Cisco estimates that by 2021, 82% of all internet traffic will be video. The practices that leverage video now will have a significant competitive advantage during the coming years. 11. Print sleep apnea brochures to place throughout your practice. Include your

new logo, phone number, and sleep website address on the brochure. A well-executed brochure will act as a conversation starter, educate patients, and make it easy for them to refer others to you.

In Conclusion

Implementing these 11 steps will not only increase your visibility and build your brand as a sleep provider, they will also go a long way towards positioning you as the go-to authority for sleep apnea treatment in your target market. For additional strategies on attracting sleep patients, visit the blog at DentalSleep Marketing.com. Marc Fowler is the founder of Bullseye Media. Since 2006, the team at Bullseye Media has provided branding, website design, video and online marketing services for dental practices across the U.S. and Canada. He can be reached at Marc@BullseyeDental.com or 214-592-9393.

BRANDING YOUR DENTAL SLEEP PRACTICE If you’re serious about growing a sleep practice, you need a stand-alone brand identity. Visit DentalSleepMarketing.com/branding to watch the video and see if your market is available.

DentalSleepM arketing.com

DentalSleepPractice.com

SURVEYresults

Physicians and Medical Insurance

here are four players around the sleep apnea table: Patients, Physicians, Dentists, and Payers. How do we all work together?

Payer Orientation for Oral Appliance Therapy...

Physician Relationship...

52%

Patients who have not seen a sleep physician but are high risk are always referred to the specialist before any therapy.

33%

I have a close relationship with board certified sleep physicians near me and work with them to manage patients.

18%

10% 3%

I use other physicians (such as ENT) when I need a prescription for therapy.

71% by sleep and primary care physicians soon

32 DSP | Summer 2019

Dental insurance should pay

58%

24% 11%

Is appropriate so I am a provider in one or more plans.

Determines who pays cash and for whom I bill insurance.

I do not involve any physicians in the therapy I provide.

Physician Risk to Dentist-supplied Custom OAT: I think custom OAT will be provided...

15%

Medical insurance should pay

Reimbursements: The amount that medical insurance pays...

30%

I use a sleep physician to interpret sleep tests only and primary care physicians to provide prescriptions for therapy.

68%

People should pay out of pocket

Is inappropriate so I have not enrolled as a provider in any medical plan.

by non-dentists and non-physicians

always by dentists only

32%

Patients pay cash and I only provide the paperwork needed to seek reimbursement.

by only ENT doctors

SURVEYresults Appointments Prior to Deliveries...

62% TWO ONE 24% 12% THREE OR MORE 2% N/A

Scheduled Appointments after Delivery within the First 90 Days...

appointments

appointment for consultation, exam, and records

57% Two follow-up appointments

appointments

25% Three or more

14%

Effectiveness: Patients...

One

25%

Report when their subjective symptoms are resolved and that’s all

23%

Are referred to diagnosing physician when subjective symptoms are resolved

63%

Are dispensed HSAT/pulse oximetry in my office for effectiveness testing and referred to their physician when these tests show positive results

4% N/A

Critical to success is communication between all our patient’s providers. How do you share information with your patient’s care team?

Are dispensed HSAT/pulse oximetry in my office and referred with these tests in hand for physician evaluation regardless of outcome of the test

12%

Communication with Physicians..

25%

I send letters to only the sleep/ diagnosing physician

34 DSP | Summer 2019

28%

Letters go out to every physician the patient sees

61%

I send comprehensive notes about patient visits/treatment

My notes are basic, with few details

11%

Letters are sent for almost every patient visit

10%

I send a letter when starting therapy & for follow-up testing

I don’t send letters to physicians

CONTINUING education

Dental Sleep Medicine: A Case Study of a TMD Patient with a 24-year History of Refractory Epilepsy Entirely Controlled with a Mandibular Advancement Device by Daniel E. Taché, DMD

nd if tonight, my soul may find her peace in sleep, and sink in good oblivion, and in the morning wake like a new-opened flower, then I have been dipped again in God and new-created. – D.H. Lawrence

Why Publish This Case Report?

My decision to publish the outcome of this one TMD case was threefold: 1. Hypothesis: Epilepsy can be solely a comorbid condition of undiagnosed/untreated sleep-related breathing disorder and that an intraoral airway device can greatly enhance efficacy of treatment when anti-epileptic drugs (AEDs) are insufficient. It had never occurred to me that I would publish this case report because it started out as do many we treat in our TMD & Sleep-Related Breathing Disorders (SRBDs) limited practice. I begin each case expecting a positive outcome; the result in this case turned out to be surprising and challenging. This case report concerns a 34 y.o. woman who came to us complaining of severe jaw pain upon awakening and “teeth grinding.” As she accepted and cooperated with our treatment plan, she was progressing well and reported a significant decline in her daily pain. She reported that she was grinding her teeth less. Everything changed approximately 15 months after we had initiated treatment when, in the same week, I was paid a visit by her (adopted) mother and received a phone call from her neurologist of nearly 24 years. They informed me that EJ had has a surprising change in her medical status. I had known since the comprehensive examination

Educational objective

and what I thought was an exhaustive Past Medical History (PMH) 15 months earlier that my patient, EJ, had been diagnosed with epilepsy at the age of 10. As you’ll see, her report was shallow, I was focused on the immediate problem, and I knew little about any connection between epilepsy and TMD or SRBD. Briefly, none of her treatment had resolved the epilepsy and she continued to have seizures weekly for all of those years. What I learned that week was that since the first night that she wore the intraoral device we provided for her TMD, she had not had a single seizure! This happy result continues to this day. Naturally, I was compelled to learn more about epilepsy. I was most interested in the possible correlation between undiagnosed SRBDs and epilepsy because the intraoral device that we provided did address the intra-articular (TMJ disc displacement) component of her TMD problem but it also addressed her sleep-related bruxism, because I hypothesized that it augmented what did appear to me to be a problem of sleep fragmentation due to airway instability/collapse while sleeping. What I found after I began to review the epilepsy literature was confusing when con-

Dental Sleep Practice subscribers can answer the CE questions on page 46 to earn 2 hours of CE from reading this article. Correctly answering the questions will exhibit the reader understands: The reason for publishing this case report is to underscore the need for the dentist to be aware of multiple problems presenting in one patient will demand vigilance in documentation and observation of symptoms. One problem might seem paramount, but the clinician must keep asking questions until the true extent of the patient’s condition is discovered. In this case, a surprising result prompted inquiry by the treating dentist, adding to his clinical expertise and prompting further questions. Curiosity in clinical practice will yield more complete patient care. This report was compiled in the hopes of stimulating similar curiosity in the reader-clinician.

36 DSP | Summer 2019

CONTINUING education sidered in the context of this case. The general views regarding the epilepsy/SRBD relation was that “excessive daytime sleepiness is a common complaint of epileptics” (Piperidou, 2008), “examples of sleep-related disturbed behaviors (parasomnias) are epilepsy or asthma” (Stores, 2007), “patients suffering with epilepsy frequently complain of unrefreshed sleep” and “the prevalence rate of OSA can be very high” (Malow, 2000). In spite of the significant amount of evidence which strongly suggests a bi-directional correlation between epilepsy and OSA, most authors portray the issue of sleep disturbances as merely a comorbidity rather than an isolated medical condition that is actually provoking the epileptic seizures. One article struggled to explain the possible correlation by hypothesizing that “antiepileptic drugs (AED) influence OSA as can barbiturates and benzodiazepines,” and “weight gain in patients treated with valproate, may precipitate or exacerbate OSA.” It seemed to me that the authors of so many articles could not allow themselves to conclude at any point that epilepsy may solely be a comorbidity of OSA and that merely identifying and treating the OSA might be sufficient. My literature review proved to be very frustrating when considered in the light of EJ’s outcome. Further review surprisingly revealed a possible explanation for this thought-process shortcoming: deficiencies in the training of healthcare professionals. As long as conventional history-taking fails to include evidence-based sleep screening tools for SRBD it is unlikely that sleep disorders will be correctly identified. Surveys of medical schools curricula have revealed that out of a typical 5 year undergraduate course of study, the median time spent on formal teaching about sleep and consequent comorbid diseases ranges from 5 minutes – 2 hours! (Stores, 2007) (Stores, 2009) After talking with EJ’s neurologist, I was confident that our hypothesis was confirmed: that her TMJ dysfunction is largely a comorbidity of sleep fragmentation, mostly shown by her sleep-related bruxism. This sleep fragmentation has regularly provoked her epileptic seizures for nearly 24 years. My confidence stems from the observation that the epilepsy is now completely controlled by use of an intraoral Mandibular Advancement Device. So, why did I feel that this case report should be published? “Clinicians can contrib-

ute to scientific knowledge significantly in a variety of ways and the Case Report can be an effective means to identify new diseases or (epidemiologically-speaking) the adverse effects of new exposures and new links between an exposure and a disease” (Aschengrau, 2013). Case reports are certainly lower down on the pyramid of evidence however, they do have a place in advancing scientific knowledge. Case reports can add clarity to cause and effect by creating links between a condition and a clinical manifestation or an outcome of treatment of that “condition” that heretofore, had not caught the attention of others. Quite often, as in the case reported herein, because of bias. The discovery of AIDS and the relationship between breast cancer and ionizing radiation are just two of many diseases that were first mentioned in case reports. 2. Inform: to inform you, the dental clinician, of the inescapable fact that all “... den-

Hierarchy of Evidence Meta Analyses Randomized Controlled Between-subject Within-subject Studies Cross-sectional Studies Case Reports Professional Articles and Reference Texts Ideas, Opinions, Editorials, Anecdotal

Daniel E. Taché, DMD is a graduate of Tufts University School of Dental Medicine and completed an advanced General Dentistry Residency program with the Veterans Administration in Houston, TX, where he first practiced TMD/Pain therapy before relocating to Wisconsin. Dr. Taché attended an 18-month training program for the diagnosis and treatment of Myofascial Pain Dysfunction (MPD). Between 2008-2010 he conducted research on the relationship between Fibromyalgia and sleep disorders. He is a staff member of the TMJ & Orofacial Pain Treatment Centers, based in Milwaukee, and his practice of dentistry in Wisconsin is limited to TMD/Orofacial and Dental Sleep Medicine. In 2009, Dr. Taché was elected for a 3-year term as President of the Wisconsin Sleep Society. He currently serves on the Board of Directors. Dr. Taché is married to Kathy, his wife of 30 years, and has four children.

DentalSleepPractice.com

CONTINUINGâ&#x20AC;&#x160;education tal patients were found to have a high pretest probability of having undiagnosed OSA,â&#x20AC;? much higher than that of the normal population. Estimates show a prevalence of 33% of males and nearly 19% of all female dental patients who present for general dental procedures and/or hygiene, to be at high risk for SRBD (Levendowski D. M., 2008). An equally disconcerting fact is that in a primary care medical setting, the prevalence of patients at risk for SRBDs is similar to that of general dental practice yet, numerous surTable 1: Risk Factors for Sleep-Related Breathing Disorders Clinical Observation

Potential Relationship

Tongue Coated

Risk for gastroesophageal reflux disease or mouth breathing

Enlarged

Increased tongue activity; possible OSA

Scalloping at lateral borders (crenations)

Increased risk for sleep apnea22

Obstructs view of oropharynx

Mallampati score of I or II: lower risk for OSA; Mallampati score of III and IV: increased risk for OSA

Teeth and Periodontal Structures Gingival inflammation

Mouth breather; poor oral hygiene

Gingival bleeding when probed

At risk for periodontal disease

Dry mouth (xerostomia)

Mouth breather; may be medication related

Gingival recession

May be at risk for clenching

Tooth wear

May have sleep bruxism

Abfraction (cervical abrasion/wear)

Increased parafunction/clenching

Airway Long sloping soft palate

At risk for OSA

Enlarged/swollen/elongated uvula

At risk for OSA/snoring

Extraoral Chapped lips or cracking at the corners of the mouth

Inability to nose breath

Poor lip seal; difficulty maintaining a lip seal

Chronic mouth breather

Mandibular retrognathia

Risk for OSA/snoring

Long face (doliocephalic)

Chronic mouth breathing habit

Enlarged masseter muscle

Clenching/sleep bruxism

Nose/Nasal Airway Small nostrils (nares)

Difficulty nose breathing

Alar rim collapse with forced inspiration

At risk for OSA/sleep-breathing disorder

Posture of the Head/Neck Forward head posture

Airway compromise and restriction

Loss of lordotic curve

Chronic mouth breather

Posterior roation of the head

Tendency to mouth breath

Bailey DR, Hoekema A. Oral Appliance Therapy in Sleep Medicine Clinics 2010;5(1):91-98.

38 DSP | Summer 2019

veys have shown that Primary Care Physicians (PCPs) do not routinely screen patients for OSA (Mold, 2011) (Sorscher, 2008). More specifically these surveys reported both a low rate of recognition and diagnosis of sleep disorders in both outpatient and inpatient health care settings. The range of rates of patients who were both identified and referred for treatment were a dismal 0.1 - 3.1% of all patients (Rosen, 2001) an alarming statistic. 3. Implore: to implore you to consider the moral or categorical imperative of NOT examining your patients for SRBD in light of the failure of the medical profession to do so and even more so because of the relative ease of identifying dental patients at risk. Even a cursory intraoral & extraoral inspection, coupled with the simplest of evidence-based screening tools, makes identification of patients who should be referred for a sleep study relatively simple, especially when the clinician also has at hand Past Medical and Family history documentation. Every medical professional is compelled to identify at-risk patients because undiagnosed/ untreated sleep disorders carry an increased risk of developing physical and psychiatric illness, among them notably cardiovascular disease, complications in pregnancy, diabetes, anxiety, depression, and alcohol and other substance abuse. It is my hope that consideration of this background information, coupled with the clinical case which you are about to consider, that even if you do not intend to actually treat the DSM patient, that you will feel compelled to seek, in a more formal way, seminars/ courses regarding DSM so that you will begin to institute a screening program within your practice. You must begin to identify patients at risk for SRBD and make arrangements to refer them to a competent clinician if you have no plans to treat such patients. Dental sleep medicine is perhaps the most rapidly expanding dental service today. Current evidence (Ramar, 2015) shows that oral airway devices are as effective as nasal CPAP in the treatment of snoring and mild to moderate OSA. Although as dentists we cannot diagnose OSA, it is within the scope of the practice of dentistry to facilitate our patients being identified and referred to qualified sleep specialists. After diagnosis, when appropriate, our DSM services may help a vast majority of these patients.

CONTINUING education

Figure 1: Clinical signs representing risk factors for SRBD: Severe retrognathia/reduced cricomental distance (Gjevre, 2013), Macroglossia, Cervical erosion, Evidence of severe bruxism, Habitual mouth-breathing, Abrasion, Narrow dental arches/anterior open bite (Bailey, 2010)

4. Opportunity: opportunity to treat patients who are seeking your services because their quality of life has been so adversely affected by their untreated SRBD. DSM has added a great deal of meaning to my practice as it has for many because we are treating life-degrading/life-threatening disease and our patients understand this and want your expertise. As was stated previously, if our dental population has SRDB as high as 33% male and 19% female, your patients who complain of “grinding” and have TMD signs and symptoms are at high risk of SRBD, with as many as 42-47% with both disorders. (Smith M. W., 2009). The implication is obvious, namely that “clinicians who are treating TMD patients need to be ever vigilant that their patient has a high probability of having an undiagnosed SRBD. You should be screening “all patients for sleep disorders and you should be developing relationships with board certified sleep physicians who will help facilitate getting your patients diagnosed and treated with oral airway devices and/or nasal continuous positive airway pressure devices” (Smith M. W., 2009). This is now the standard of care in dentistry. The bar has been raised and we must all be up to the task. Table 1 to the left along with the Figure 1 photographs are a fairly comprehensive list of dental signs and symptoms which often present in patients with fragmented sleep. These signs and symptoms of SRBD are encountered by nearly all dentists, both the general and specialist dentist alike daily in their practice of dentistry. Unfortunately, too often these signs and symptoms are viewed by the profession as primary DENTAL COMPLICATIONS, not co-morbid conditions signaling a more ominous condition hence, the symptom is treated,

Figure 2: EJ when she presented for her TMJ exam Figure 3: Meet EJ, age 10, when seizures began

and the patient is released unaware that this medical problem exists which will continue to degrade their health.

Meet EJ

This is a case study of a patient who was referred to our office for treatment of “TMJ” pain. The very favorable outcome was far more than either EJ or we expected and can be attributed to applying knowledge and skills in dental sleep medicine. Important: remember however, that suspecting a problem is not a diagnosis, only a suspicion. Currently, diagnosing OSA is not within the scope of the practice of dentistry; a diagnosis is reserved for a board-certified sleep medicine specialist.

EJ’s Chief Complaints

• EJ (Figure 2) is a 34-year-old female patient who was referred to our TMJ/OFP clinic by her primary care physician for “TMJ” pain. • EJ described her Chief Complaints (CC) as: º bad night sleeping, she grinds her teeth when she is not sleeping well DentalSleepPractice.com

CONTINUING education º she has noticed that when she grinds her teeth, she awakens with jaw pain º she has teeth pain day and night after a bad night’s sleep, º when not sleeping well: - often awakens feeling sweaty - 3-4 “bathroom breaks” throughout the night • EJ began to chronicle her very extensive Past Medical History (PMH) but in very general terms because EJ was referred to us for her jaw pain and nocturnal teeth grinding; at the time, there was no suspected correlation between the pain that she often awakened with and her seizures • EJ told us that she has been diagnosed with epilepsy dating back for “...more than 20 years ...” beginning when she was only 10 years old which was when she experienced her first “seizure”. I later learned that pediatric seizures are a fairly common problem and that most often the seizures do not recur and if they do, they typically respond to one of several Anti-Epileptic Drugs (AEDs) • Important to Note: EJ, at the time of her initial examination, was 34 years old and although she did inform us that she had been diagnosed with epilepsy, she did not provide much more history on the subject other than that she had been taking AEDs for nearly 24 years. Because EJ had significant neurocognitive problems from her condition, she offered a relatively superficial history at the time of her initial exam and it would be more than a year later that we learned the real history of her epilepsy problem.

EJ’s Past Medical History (PMH)

• Figure 3 shows EJ when she was approximately 10 years of age when her seizures began. • Her very first seizure occurred in 4th grade while standing in line at a water fountain. She lost consciousness completely for “a couple of minutes” • EJ was seen by a neurologist who prescribed Phenytoin to prevent future seizures • The seizures became more frequent despite being on the Phenytoin • It was noted that all of the subsequent events would occur while she was asleep • Her condition was reclassified from Idiopathic Seizures to Epilepsy

40 DSP | Summer 2019

EJ’s Seizure Treatment: Pharmacological

• AEDs are typically quite effective in controlling pediatric seizures and one AED is sufficient in about 60 percent of children. • It is notable that by the time I met EJ she was taking as many as five (5) drugs concurrently and she still had sporadic seizures.

Seizure Treatment: Neurosurgery

• EJ’s response to the Phenytoin was poor. • A brain “lesion” was found on a scan and neurosurgery was recommended. • Surgery was performed, in fact, she had 3 procedures, including a Vagus Nerve Stimulator (VNS). • VNS typically will reduce seizures by 50% (Elliott, 2011) however, EJ did not realize any benefit. • EJ’s seizures, up until the point of surgery, had all occurred while she slept. Following neurosurgery, seizures were now occurring both day and night.

Pediatric Seizures/Epilepsy: Background

• Nearly 120,000 children experience a first or newly diagnosed seizure annually. • Of first-time pediatric seizure victims approximately 45,000 children will experience recurrence of their seizures º 60% of the time it will not recur for a decade or more (N. Aprahamian, 2014). º If there are 2 or more recurrent seizures without a proximal cause for the seizures (Speltz, 2014) this condition will then likely be reclassified as epilepsy. • Provoked Seizures: seizures that follow a discrete event such as: º Trauma º Hypoglycemia º High fever º Provoked seizures rarely recur after the precipitating condition (fever; infection) has been identified • Unprovoked seizures: seizures which do not have an obvious immediate precipitating event. The nature of these seizures suggests the possibility of an underlying neurological disorder or serious medical condition that might predispose a child to recurrent seizures such as: º Genetic and congenital malformations º Intrauterine and postnatal insults º Anoxic injuries º Infections (viral and bacterial)

CONTINUING education

Figure 4: EJ’s Mandibular range of motion

º Vascular malformations and compromise (e.g. Ischemia) º Trauma º Tumors º Seizures with unknown etiology

Figure 5: TMJ, sagittal view - open (bottom) and closed (top)

Temporomandibular Joint Clinical Evaluation

• Figures 4 shows the TMD examination. • Maximum opening (MO) was moderately limited at 35mm • Lateral movement was normal at 10mm • Muscle palpation: multiple muscles were tender to palpation most notably a) bilateral superficial masseters, bilateral lateral pterygoids, anterior temporalis, mid-temporalis, and splenius muscles • External palpation of the TMJ capsules was unremarkable • Palpation of the TM joints (via EAMs) revealed what appeared to be normal function despite the somewhat limited maximum opening º no evidence of TMJ disc displacement • Painful paired muscles, normal TM joints, and the report of pain nearly every morning would imply that bruxism (SB) was likely the source of her pain. • Nonetheless, TMJ imaging will be ordered to make certain that nothing is left to question.

• These cone beam images were read by a board-certified radiologist • The images were described as “normal osseous morphology and condylar position” • The right condylar process and mandibular ramus were slightly shorter than the left but this was considered a normal variation • Summary: normal TM joints and apparent normal function

Radiographic Evaluation: TMJ Cone Beam CT Images

Radiologist Comment on Sinuses and Airway: Perhaps the Missing Link

• Figure 5 shows EJ’s TM joints from a sagittal perspective

Figures 6A-6B: CBCT image/axial view A. EJ’s airway. B. Normal airway

Figure 7: Radiologists comments

• The radiologist who read the CBCT images made very interesting comments under

DentalSleepPractice.com

CONTINUING education the “Sinuses and Airway” which, in the absence of overt TMJ disease, compelled me to approach this “tooth grinding” and “pain upon-awakening” case as symptoms secondary to a SRBD • Above you will see a portion of the final comments made by the radiologist regarding the size of EJ’s oropharyngeal airway. • Figure 6 is for comparative purposes contrasts the A-P dimension of a normal sized airway to a subnormal sized airway • It is easy to see that EJ’s airway is grossly subnormal in size and a definitive risk for SRBD; a likely contributing factor to sleep bruxism and orofacial pain.

Looking More Closely: Intraoral Risk Factors for SRBD

• Figure 8 is an intraoral view of Ej’s mouth • The soft tissue appearance seen in EJ are risk factors for SRBD, specifically: º narrow and deep palate, º coated and scalloped tongue and º a tongue size that seems enlarged compared to the dental arches (Liistro, 2003)

Looking More Closely: Extraoral Risk Factors for SRBD • Figure 9 accurately portrays EJ’s severe Forward Head Posture (FHP). • FHP may well represent anatomical differences unique to patients who will/have SRBD. Anatomical factors contributing to the etiology of OSA have extensive support in the literature. • Whether these anatomical variances represent adaptive changes consequent long-

Figure 8: EJ viewed intraorally; multiple risk factors for SRBD

42 DSP | Summer 2019

standing OSA which has not been addressed, or reflects phenotypic differences of airway morphology, which may predispose one to developing a SRBD, is debatable. • Nonetheless, it is important to know the predominant anatomic alterations in individuals with apnea, so that health care professionals can identify the risk factors and refer the patients for proper diagnosis and treatment (Piccin, 2016)

Hypothesis: Address EJ’s Apparent SRDB which will Reduce Microarousals which Cause Her SB

• Figure 10 shows EJ habitually has her mouth open during the day; perhaps more easily appreciated by looking back at Figure 9 – side view. • Daytime mouth breathing is more common among patients who may have SRBD and screening is advised in order rule out a problem (Detailleur, 2017) • This “condition” or habit, is perhaps a bit less obvious risk factor for SRBD but given EJ’s past medical history, it took on more significance as we were developing this case

Treating EJ: Fixing Her Airway and Her Pain... and Much More!

Addressing EJ’s pain complaints by addressing what appears to be a SRBD was made and well supported by clinical evidence presented herein and current literature (Lavigne, 2007); (Smith M. W., 2009). We decided to provide EJ not with a single arch TMJ splint but a Mandibular Advancement Device (MAD), specifically a Myerson

Figure 9: EJ side view. Pronounced forward head posture (FHP)

Figure 10: EJ full face view. Daytime mouth breathing

CONTINUING education

Figure 11: The EMA® an airway stabilizing device

EMA® (Figure 11) because the design is an elegant solution to controlling the cause of her pain: SRBD which leads to sleep bruxism. The Myerson EMA® by design, lends itself nicely to managing these sorts of TMD/Sleep cases which I suspect are far more prevalent in our practices than current literature might suggest. The EMA® (Figs. 11-14) is a two-part appliance consisting of an upper tray and separate lower tray; the trays are connected by elastic straps on either side called Durometers® . When both trays are connected keeping the mandible advanced while sleeping, it is very effective to do what it was originally designed to do...maintain a patent airway while sleeping or more specifically control obstructive sleep apnea (Figure 11). Another very useful feature of this particular MAD is that the trays can be easily separated and the mandibular tray can be worn independently for daytime use for preventing disc displacement. In the case of EJ, it also served as a habit-control device specifically for helping to reduce daytime bruxism which we found to be instrumental in helping to control her daytime pain.

A Surprise Ending

EJ was provided with the EMA® and she was very compliant with my request to wear the lower tray during the day and the dual appliance (both attached) while sleeping. I was very happy to hear, after only a week or so, that her symptoms were rapidly resolving. It was not many weeks into treatment when her aunt (who was also her guardian) began to accompany EJ to her follow-up progress evaluations. She wanted to express her happiness with just how much better EJ was doing symptomatically, declaring how much her pain had declined and how much less she was now awakening at night because she was

Figure 12: The EMA® is being used here as a single arch device that will serve to prevent TMJ disc displacement and/or control daytime bruxism by disconnecting the straps (Durometers) connecting the upper and lower trays.

Figure 13: The EMA® is very useful both for SRBD and managing TMJD

Figure 14: The EMA® in place to reduce resistance to breathing

no longer having to “wake up all night to go to the bathroom.” Treatment progressed very well, and I kept EJ in treatment for approximately one year. After twelve months, we reduced the use of her EMA® to nighttime only and EJ continued to do very well. It was remarkable how animated and happy she was each time she returned for a follow up visit. So much improved, that now she was working as a volunteer “every week, part-time.” Her aunt told me that she had not been able to hold any sort of a job for years because of her “health problems”...not much more was said at that time. It would be approximately 15 months since she began therapy, that we learned more about her life before the EMA®. I learned that EJ had DentalSleepPractice.com

CONTINUING education been medically disabled due to her uncontrolled epilepsy since age 10. EJ and her aunt went on to tell us that from the very first night that she wore the EMA® that she has NOT HAD A SINGLE SEIZURE! Which is why she was now able to keep a job for the first time ever in her life. Also, she informed us that her neurologist had begun to withdraw her AEDs, one-by-one, and that instead of five AEDs, she was now only taking two, and it was her neurologist’s goal to withdraw her from ALL her AEDs by the end of this year (2019). Hearing this, I decided to refer EJ for a polysomnogram to better understand perhaps how fragmented sleep might explain the genesis of her prior-to-MAD uncontrolled epilepsy. EJ had a previous PSG but it was interpreted as “inconclusive”. We ultimately obtained a copy of all available medical records from the time that she had been diagnosed with epilepsy. The PSG report I saw was only a summary and did not provide an index of respiratory-related arousals. I did request that esophageal

manometry (aka: PES) be applied during her upcoming PSG because given her past medial history, even non-apneic events from increased “effort” of breathing could contribute to sleep fragmentation, which we want to keep to a minimum. If her EMA cannot fully resolve her SRDB, I will suggest combination therapy, i.e. CPAP + her EMA. While waiting for her PSG, we provided EJ with a Home Sleep Test Monitor (HST – ARES Watermark brain monitor) to determine if she had a SRBD. We were clear with EJ that the results of this 3-day HST trial would not constitute a diagnosis and that only a certified sleep specialist could make a final diagnosis. EJ understood that regardless of the outcome, that a referral for an attended PSG was indicated. We provided EJ the HST for three successive nights. She was instructed to withdraw the EMA® for night #1, but nights #2 and #3, she would use the EMA as she always had. You can see from the results below in figure 15, that there certainly appears to be significant breathing-related sleep fragmentation on night #1 and that on nights #2 and #3, that the fragmentation is appreciably reduced to nearly zero. I will not attempt to interpret the HST report but the improvement in respiratory indices is quite obvious.

Why is This Case Report Important?

Figure 15: The Watermark Home Sleep Test Report: EMA® seems to be controlling the pateint’s SRBD well

44 DSP | Summer 2019

A review of current medical literature exploring sleep disorders and childhood epilepsy is aptly summarized in a report of a study performed at the University of Calgary “... children with epilepsy had significantly greater sleep problems than their non-epileptic siblings....” (Wirrell, 2005). The conclusion seems to reflect selection bias that sleep problems and epilepsy are unidirectional or simply stated that seizure disorders are a risk factor for pediatric sleep problems. The case report presented here would suggest something quite contrary: that there is a bi-directional relationship between pediatric sleep problems and epilepsy, that an unaddressed SRBD is a risk factor for refractory pediatric epilepsy. A bi-directional correlation between pediatric sleep problems and epilepsy is anathema to the bulk of current scientific literature that views the degradation of sleep quality which is common to most epileptics as merely a co-morbidity of the epilepsy, i.e. that it is a uni-directional correlation. Again, I feel that

CONTINUING education is a demonstration of selection bias against SRBD as possibly etiologic solely because of the minimal education of healthcare professionals on the subject of sleep-disordered breathing as previously stated.

Concluding Remarks I learned a great deal from this case. It was interesting that a significant percentage of cases of epilepsy in children remains idiopathic (Berg, 2001) which could mean that the inherent bias from a lack of sufficient education in sleep disorders is preventing their clinicians from including SRBD in their differential diagnosis. This was clearly the case with EJ because, despite the effort of her doctors to treat her epilepsy, it remained refractory to medication. No one noticed that all of her seizures occurred WHILE SHE WAS SLEEPING and thought to pursue a thorough sleep assessment. I feel that it was my education in sleep medicine/dental sleep medicine that enabled me to understand the more subtle aspects of EJ’s case, much to her benefit. My goal was 1. 2. 3.

10.

11.

12.

13.

14.

Aschengrau, A. a. (2013). Essentials of epidemiology in public health. ones & Bartlett Publishers. Bailey, D. a. (2010). Oral appliance therapy in sleep medicine. Sleep Medicine Clinics, 5(V), 91-98. Berg, A. S.-R. (2001). Defining early seizure outcomes in pediatric epilepsy: the good, the bad and the in-between. . Epilepsy Research, 43(1), 75-84. Detailleur, V. B. (2017). Are Sleep Disordered Breathing Symptoms and Maxillary Expansion Correlated? A Prospective Evaluation Study. Journal of Sleep Disorders: Treatment and Care. Elliott, R. E. (2011). Vagus nerve stimulation in 436 consecutive patients with treatment-resistant epilepsy: long-term outcomes and predictors of response. Epilepsy & behavior, 20(1), pp. 57-63. Gjevre, J. T.-G. (2013). Inter-observer reliability of candidate predictive morphometric measurements for women with suspected obstructive sleep apnea. Journal of Clinical Sleep Medicine, 9(07), pp. 695-699. Gold, A. (2011). Functional somatic syndromes, anxiety disorders and the upper airway: a matter of paradigms. Sleep medicine review, 15(6), pp. 389-401. Jonas, D. A. (2017). Screening for obstructive sleep apnea in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA, 317(4), 415-433. Kato, T. R. (2001). Sleep bruxism: an oromotor activity secondary to micro-arousal. (.. ,.-1. ., Ed.) Journal of dental research, 80((10)), 1940-1944. Kryger, M. R. (1996). Utilization of health care services in patients with severe obstructive sleep apnea. Sleep, 19(suppl_9), S111-S116. Lavigne, G. H. (2007). Genesis of sleep bruxism: motor and autonomic-cardiac interactions. Archives of oral biolog, 52(4), 381384. Levendowski, D. M. (2008). Prevalence of probable obstructive sleep apnea risk and severity in a population of dental patients. Sleep and Breathing, 12((4)), 303-309. Liistro, G. R. (2003). High Mallampati score and nasal obstruction are associated risk factors for obstructive sleep apnoea. European Respiratory Journal, 21(2), 248-252. Malow, B. L. (2000). Obstructive sleep apnea is common in medically refractory epilepsy patients. Neurology, 55((7)), 1002-1007.

to reduce her daily pain. To do so it meant I had to control her sleep-related bruxism. I suspected a SRBD triggered her bruxism. The radiology report plus data that shows women with polycystic ovary syndrome (another of EJ’s medical problems) have 30x the risk for SRBD, clearly supported my clinical impression that her TM “J” problem paled in comparison to her airway problem (Kato, 2001). The evidence guided our clinical decisions so the choice to employ the EMA to help her with her pain was simple, Figure 16: EJ today – 40 lbs. lighter and feeling great! logical, and based on evidence. Limitations of this case: It is a single case without controls. Because of EJ’s life-changing outcome, the significance of the implications of this case report cannot be overstated. It is our plan to develop and initiate a randomized controlled crossover trial may be of great benefit to prove or disprove the hypothesis that sleep fragmentation is a risk factor for refractory epilepsy and can be treated with mandibular advancement devices (Selye, 1956) (Gold, 2011). 15. Mold, J. Q. (2011). Identification by primary care clinicians of patients with obstructive sleep apnea: a practice-based research network (PBRN) study. The Journal of the American Board of Family Medicine, 24((2)), 138-145. 16. N. Aprahamian, M. H. (2014). Pediatric first time non-febrile seizure with focal manifestations: Is emergent imaging indicated? Seizure, 23(9), 740-745. 17. Olmos, S. (2016). Comorbidities of chronic facial pain and obstructive sleep apnea. Current opinion in pulmonary medicine,, 22(6), 570-575. 18. Piperidou, C. K. (2008). Influence of sleep disturbance on quality of life of patients with epilepsy. Seizure, 17((7)), 588-594. 19. Ramar, K. D. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. Journal of clinical sleep medicine, 11((07)), 773-827. 20. Rosen, R. Z. (2001). Low rates of recognition of sleep disorders in primary care: comparison of a community-based versus clinical academic setting. Sleep Medicine, 2((1)), 47-5. 21. Selye, H. (1956). The stress of life. 22. Smith, M. W. (2009). Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep, 32(6), 779-790. 23. Smith, M. W. (2009). Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep, 32((6)), 779-790. 24. Sorscher, A. (2008). How is Your Sleep: A Neglected Topic for Health Care Screening. The Journal of the American Board of Family Medicine, 21((2)), 141-148. 25. Speltz, L. (2014). Assessing First Seizures in Children and Adolescents. A Pediatric Perspective, 23(1), VOLUME, NUMBER. 26. Stores, G. (2007). Clinical diagnosis and misdiagnosis of sleep disorders. Journal of Neurology, Neurosurgery & Psychiatry, 78((12)), 1293-1297. 27. Stores, G. (2009). Errors in the recognition and diagnosis of sleep disorders. Progress in Neurology and Psychiatry, 13((6)), 24-33. 28. Wirrell, E. B. (2005). Sleep disturbances in children with epilepsy compared with their nearest-aged siblings. Developmental medicine and child neurology, 47(11), 754-759.

DentalSleepPractice.com

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Dental Sleep Medicine: A Case Study of a TMD Patient with a 24-year History of Refractory Epilepsy Entirely Controlled with a MAD by Daniel E. Taché, DMD 1. The general views regarding the epilepsy/SRBD relation hold that ______. a. Excessive daytime sleepiness is a common finding in epileptics b. Examples of parasomnias include are epilepsies and asthma c. Patients suffering from epilepsy frequently complain of unrefreshing sleep d. The prevalence of OSA in epileptics can be high e. All of the above 2. Surveys of medical school curricula have revealed that undergraduate medical students receive formal training in sleep and related comorbidities equivalent to ______. a. One semester’s lecture without clinical exposure b. Between five minutes and two hours c. Most of a sleep fellow’s residency requirements d. That found in most dental schools 3. Case Reports can be a valuable way for medical professionals to ______. a. Link disease and clinical manifestation and treatment outcome b. Promote novel treatments to the profession at large c. Find solutions to disease without expensive clinical trials d. Establish credibility for their unique approach to medicine

46 DSP | Summer 2019

4. Primary Care Physicians have been found to screen their patients for OSA ______ a. Routinely, often followed by a referral for diagnosis b. When pressed by family members reporting symptoms c. Under 5% of the time, even during inpatient encounters d. Never 5. The following is not a frequently found sign of SRBD ______. a. Enlarged masseter muscles b. Loss of lordosis c. Chronic mouth breathing d. Predisposition to alopecia

c. Three or more seizures are required to ‘qualify’ for a diagnosis of epilepsy d. These are generally categorized as ‘Provoked’ or ‘Unprovoked’ seizures 8. Which is NOT true of Myerson EMA oral appliances ______. a. The trays can be worn separately for different clinical therapies b. The connecting straps are called “Durobraces” c. The mandible can be positioned in any relation to the maxilla d. It is useful to control daytime bruxing habits

6. Signs and symptoms of SRBD are often confused with ______. a. Unrelated dietary allergies b. Dental complications c. Patient’s explanation of their problem d. Too much information from consumer sleep technologies

9. The clinical outcome in this case report seems to indicate ______. a. That SRBD caused epilepsy in this patient b. There might be a bidirectional relationship between SRBD and epilepsy c. TMD pain, once resolved, no longer triggers seizures d. Protruding the mandible during sleep sends neurofeedback signals that prevent epilepsy

7. Nearly 120,000 children will have a first seizure annually ______. a. Over 100,000 of them will suffer from a second episode within the next year b. If they have a second, most will have that within the next five years

10. Case Reports fall within the hierarchy of medical evidence ______. a. Above anecdotes and professional articles b. At the same level of meta analysis c. At the very bottom of the pyramid d. They are not considered ‘evidence’ at all

LASERfocus

Hot Glass Tip Diode Frenectomies ARE NOT Laser Frenectomies Do dental laser education and proficiency certifications fail patients’ and dentists’ expectations across the globe? by Peter Vitruk, PhD, MInstP, CPhys

n the summer of 2018, when traveling with the family on vacation in Europe, my 26-year-old daughter underwent an emergency operculectomy – excision of the inflamed (due to infection) soft tissue flap over an erupting wisdom tooth. We opted against a scalpel for fear of spreading the infection, the intra-operative bleeding, and other complications. The dental office did not have a surgical laser or electrocautery/electrosurgery available, so the dental diode it was. Fully understanding the limitations of the hot glass tip diodes for soft tissue surgery, we were choosing the lesser risk of infection while preparing for painkillers … and possibly a lot of painkillers just in case the diode was not used at its best. For three weeks following the surgery, the pain in the mornings was 10 out of 10 … This made me wonder even more about some of the diode frenectomies on infants, for whom painkillers are not an option. Mid-March 2019 – a video of an infant frenectomy performed with a diode’s hot glass tip was aired by the SBS TV channel in Australia.1 The images, shown in Figure 1, of the charred frenectomy site and the blood-filled suction tube are not for the faint-hearted.

Peter Vitruk, PhD, MInstP, CPhys, is a member of The Institute of Physics, UK, and a founder of the American Laser Study Club (www.americanlaserstudyclub.org), and LightScalpel, LLC (www.lightscalpel.com), both in the USA. Dr. Vitruk can be reached at 1-866-589-2722 or Peter@American LaserStudyClub.org

48 DSP | Summer 2019

In both cases above, the excisional/incisional – i.e. soft tissue cutting – diode surgeries were presented as “laser surgeries”. However, neither the excessive post-op pain, excessive tissue charring, deep thermal necrosis, or the excessive bleeding are expected during true laser surgeries performed with an appropriately configured (wavelength, pulsing and fluence) beam of laser light.2-8 So, what differentiates such diode surgeries from laser surgeries? And if the cutting diodes are indeed different from the lasers (as reviewed below), then what are the reasons that diode surgeries continue to be confused for laser surgeries?

Dental Diodes for Soft Tissue Cutting

Near-infrared (near-IR) diode laser light circa 1,000 nm is EXTREMELY WEAKLY ABSORBED by the soft tissue2,3 and, therefore, cannot optically (i.e. by the photons) ablate the sub-epithelial oral soft tissue. Instead, the diode laser optical energy heats up the purposely darkened (e.g. CHARRED) distal end of the fiber GLASS TIP to 500-900ºC,2 which then heats up the soft tissue through heat conduction from the hot glass tip. Then the soft tissue is burned off, on contact, with the hot charred glass tip. Unlike the non-contact surgical lasers (such as CO2 or Erbium lasers that vaporize tissue’s histological water by the photons of light3-8), soft tissue cutting diodes are contact thermal cautery devices, similar to electrocautery. The medical efficacy and the safe use of cutting diodes that require their tips “initiated” or “activated”, depends on multiple factors, such as:2

LASERfocus

Figure 1

• User’s technique and skill in charring the glass tip, e.g. with burnt ink or cork; • User’s hand speed and tip-tissue contact duration; • Degradation of the glass tip’s char, which reduces tip temperature and leads to mechanical tearing (cutting) of the tissue by the glass tip’s sharp edges (hence the risk of bleeding); • Biocompatibility and sterility of the char that’s produced by burned ink or cork when applying the hot tip to the soft tissue; • Biocompatibility of the hot glass and its cladding materials at 500–900 degrees Celsius operating temperatures when applying the hot tip to the soft tissue; • Risk of thermal gradient-induced fractures and disintegration (into patient’s mouth) of the hot glass tip. The only proper way to use any hot tip cautery device for incisions with minimal depth of the thermal necrosis on surgical

margins is to minimize its contact time with the tissue.8 A complicating factor when using a diode for cutting, is a halo of high intensity infrared light that surrounds the (partially “initiated” i.e. partially transparent) tip inside the soft tissue and contributes to even deeper thermal necrosis.8 Furthermore, when the hot charred tip is dragged through the soft tissue, the friction strips the char off the glass tip.9 Without the char, the glass tip cools down and may mechanically tear (cut) the tissue – which results in bleeding. Therefore, it is not surprising that both excessive thermal necrosis and excessive bleeding can occur during diode surgeries. The hot tip cautery technique is very different from the true laser surgery technique. Without knowing that a cutting diode is a hot glass tip cautery device, it is challenging for anyone to properly use it. Therefore, diode frenectomies performed with a hot glass tips should not be confused with, and should not be referred to, as laser frenectomies.

It is not surprising that both excessive thermal necrosis and excessive bleeding can occur during diode surgeries.

DentalSleepPractice.com

LASERfocus Deficiencies in Laser Dentistry Education Materials

A 5-10-minutelong hands-on laser practice on pig jaws, typical for “certification” courses, cannot make one proficient in laser dentistry or surgery.

Unfortunately, many of high profile laser dentistry education resources, for instance from the Academy of Laser Dentistry,10 do not describe soft tissue cutting near-IR diodes as hot glass tip cautery, and the important properties of hot tip cutting diodes are not taught in most of laser dentistry textbooks.11 For instance, the “Laser Fundamentals” chapter in the “Principles and Practice of Laser Dentistry” textbook11 never mentions that dental diode wavelengths cannot optically – with photons – cut the oral soft tissue; and it also fails to mention that dental soft tissue cutting diodes are hot glass tip cautery devices. Furthermore, the absorption coefficients by the soft tissue for the Near-IR diode laser wavelengths are often greatly exaggerated.10,11 Not surprisingly, dentists across the globe are misled and confused about the proper techniques of using dental diodes for soft tissue incisions. It is encouraging, however, that some of the newest laser dentistry textbooks12 recognize and point out the necessity of charring of diode’s glass tips for soft tissue cutting. The much-needed change, driven by the science of the laser-tissue interaction2-9 and by the prominent leaders in continuing dental education,13 is finally coming to laser dentistry education.

Deficiencies of Dental Laser Proficiency “Certifications”

The proliferation of Dental Laser Proficiency “Certification” courses (e.g., from the American Board of Laser Surgery)14 further confuses and misleads dentists through the false sense of being “certified”, and yet

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

not being fully trained to treat live patients with lasers. The one or two day laser dentistry classes are great as introduction to lasers. Typically, a majority of attendees at such “certification” courses have never owned or even used a laser. Such courses cannot make an attendee to become proficient in laser dentistry or laser surgery if such attendee has never treated a live patient with a laser. A 5-10-minute-long hands-on laser practice on pig jaws, typical for “certification” courses, cannot make one proficient in laser dentistry or surgery. Arguably, “Dental Laser Proficiency Certification” should include the proof of live patient laser treatment competence and excellence by the providers, and not just an over-the-weekend class.

Summary

In order to meet patients’ and dentists’ expectations across the globe, the standards for dental laser proficiency certification and the quality of the dental laser education resources must be elevated. Laser dentistry education must be based on Science of laser-tissue interaction.2 The soft tissue absorption spectra clearly define diode’s near-infrared wavelengths as non-ablative.2-9 If used for cutting, the near-infrared diodes are turned into the hot glass tip cautery devices, which operate vastly different from a true laser beam surgical device.2,3,8,9,12 Without knowing that a cutting diode is a hot glass tip cautery device, it is challenging for anyone to properly use it. Therefore, diode frenectomies performed with hot glass tips should not be confused with, and should not be referred to, as laser frenectomies.

https://www.sbs.com.au/news/the-feed/baby-tongue-cutting-trend-needs-to-stop-experts-warn?fbclid=IwAR3J67AiibLEC_e0m4DRRlG5Omw0mE-sz_aqBZNHgJ94AQ-SuxA304fa6QA. Accessed April 3rd 2019. Cosier C. Baby Tongue Cutting Trend Needs to Stop, Experts Warn. The Feed. SBS. Vitruk P. Laser Education, Science and Safety – A review of dental laser education standards. Dentaltown. 2017 June;17(6):62-67. Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Practice US. 2014;7(6):19-27. Kaplan M and Vitruk P. Soft tissue 10,600 nm CO2 laser orthodontic procedures. Orthodontic Practice US. 2015;6(6):53-57. Fabbie P, Kundel L, Vitruk P. Tongue-Tie Functional Release. Dent Sleep Practice. Winter 2016: 40-45. Geis M, Kundel L, Vitruk P. Functional Frenectomy (Osteopathically Guided). Dent Sleep Practice. Summer 2018:30-32. Riek C, Vitruk P. Incision and Coagulation/Hemostasis Depth Control During a CO2 Laser Lingual Frenectomy. Dent Sleep Practice. Spring 2018:32-38. Vitruk P, Levine R. Hemostasis and Coagulation with Ablative Soft-Tissue Dental Lasers and Hot-Tip Devices. Inside Dentistry. 2016 Aug;12(8):37-42. Romanos GE, Belikov AV, Skrypnik AV, et al. Uncovering dental implants using a new thermo-optically powered (TOP) technology with tissue air-cooling. Lasers Surg Med. 2015;47(5):411-420. http://www.laserdentistry.org/uploads/files/education/LaserEdu_IntroToLasers.pdf . Accessed April 3rd 2019. Coluzzi DJ. Fundamentals of lasers in dentistry, basic science, tissue interaction, and instrumentation. J Laser Dent. 2008;16(spec issue):4-10. Convissar RA. Principles and Practice of Laser Dentistry. St. Louis, MO: Mosby Elsevier; 2011 & 2016 Editions: Ch. 2. Colluzzi DJ, Parker SPA. Lasers in Dentistry – Current Concepts. Cham. Switzerland: Springer; 2017: Ch 4. https://www.dentaltown.com/blog/post/7255/726-dental-updates-with-gordon-j-christensen-dds-msd-phd-dentistry-uncensored-with-howard-farran . Accessed April 3rd 2019. Podcast 726. Dental Updates with Gordon J. Christensen, DDS, MSD, PhD. Dentistry Uncensored with Howard Farran. https://www.americanboardoflasersurgery.org/laser_dentistry.html . Accessed April 3rd 2019.

50 DSP | Summer 2019

Ken Berley, D.D.S., J.D.

Steve Carstensen, D.D.S. Glennine Varga, R.D.A.

Learn from experts at the new ADA Dental Sleep Medicine Conference! ADA presents the new Dental Sleep Medicine Conference, held September 4-5 in San Francisco at the ADA FDI World Dental Congress. This two-day course has been designed from the ground up to give you the information and the process you need to support how you make Dental Sleep Medicine/Airway Therapy happen for you, your team, your professional colleagues, and your patients.

Hear three of the leading experts in Dental Sleep Medicine explain each point in the ADA Policy Statement, supporting practical, you-can-do-this clinical wisdom with the latest in medical science and professional guidelines and protocols. Course code: 4113, CE Hours: 14 ADA FDI 2019 takes place September 4-8.

PRODUCTspotlight

A Success Story by Béatrice Robichaud

n 2012, Panthera Dental started to offer the D-SAD™ appliance as the newest generation of full CAD/CAM appliances. In 2016, the success of the appliance was such that Panthera launched Panthera Sleep, an entire division fully dedicated to dental sleep medicine. As a sleep dentist, you want to offer your patients the very best. If you are looking to switch from an acrylic appliance, or trying to find an alternative for a discontinued appliance such as the ResMed Narval CC, you can stop searching: Panthera Sleep is your partner of choice. Panthera appliances are the only sleep appliances designed to resist heavy bruxism. Our products come with a wide range of customization options to meet the needs of all types of patients and morphologies. You can choose from our selection of several different bands and plateaus to increase the general

D-SAD™ plateaus

Béatrice Robichaud is the co-founder of Panthera Dental, a lecturer, and a specialist in High Technology CAD/CAM dental products. She graduated in Telecommunications at Collège radio télévision de Québec (CRTQ). During her career, she led several lectures in English and French in 10 different countries and trained over 400 dental specialists in the CAD/CAM dental field. Béatrice is responsible for new product launching, product introduction on the international level, and customer technical support.

52 DSP | Summer 2019

D-SAD™ appliance

efficacy and comfort of the appliances. Our titration systems offer a wide range of possibilities and can go backward or forward by 0.5 mm increments simply by replacing parts for longer or shorter ones, ranking them among the most precise titration mechanisms of the industry. All our appliances are FDA, CE and Health Canada approved. What defines a good appliance is not limited to how comfortable, light and small it is, but also encompasses the great customer service required to assist you in all situations. Panthera Dental has always prioritized helping our client dentists. Obviously, the efficacy of the appliance needs to be up-to-date and consistent. In order to continually improve our appliances, Panthera Dental works with renowned sleep dentists, who provide scientific research and clinical testing. It’s a lot of energy and effort, but we believe it is part of our ‘why.’ If you are interested in learning more about Panthera products, we invite you to contact us or to take part in one of the numerous training classes offered by many well-known sleep dentists. For a complete list, visit www.pantherasleep.com.

BOOKreview

Book Review by Pat Mc Bride, MA, RDA, CCSH The Clinicians Handbook for Dental Sleep Medicine by Ken Berley, DDS, JD, DABDSM, and Steve Carstensen, DDS, DABDSM

As a practitioner who has been “doing” and involved in dental sleep medicine for more than twenty years I have been waiting a very long time for a publication specific to the dental sleep medicine practitioner. Read cover to cover in one cross country flight – I literally could not put it down – The Clinicians Handbook for Dental Sleep Medicine will in this author’s opinion be hailed as the seminal text on the subject for decades to come. Did I wait impatiently for this book? You bet ya! Is there something in here for everyone, even the folks who have been “into” dental sleep medicine for donkey years and think they have it dialed in? Yes, without a doubt! No one who reads this book will walk away without garnering invaluable and priceless nuggets for their practice and their patients who suffer from any myriad of breathing disordered sleep conditions. Of special note, this book is loaded with excellent illustrations and provides a large number of citations for additional reading and further education while paying homage to giants in the field such as John Remmers, MD, and Keith Thornton, DDS, along the way.

Refer to it again and again as you raise the level of your craft and improve the lives of your patients.

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If we conservatively estimate the numbers of affected people with IFL, UARS, and OSA to be 20+ million, practitioners are facing a pandemic, especially when the “gold standard” of therapy CPAP has a documented longitudinal compliance rate of anywhere from 25-50%. Truth be told, it’s more like 25% tops. As the fastest growing discipline in dentistry, dental sleep medicine offers the dental practitioner the opportunity to ethically screen and treat patients with alternate and adjunctive therapies such as oral appliances (OAT) that will drastically improve overall health trajectories for patients while adding significantly to the source of income for the dental practice. The book is thoughtfully laid out with an introductory overview of sleep and sleep disorders providing a sound foundation for each incremental step up the ladder through protocols, implementation and practice while offering solid “how to” guidance every step along the way. It closes with frank discussions regarding legal, ethical and policy issues and pulls back the curtain on a subject close to all of our hearts, pediatric sleep and breathing disorders. Refreshing and engaging in it’s Marcus Welbyish presentation, this book packs a wallop when it comes

to presenting the reality of how wading in at the shallow end without a full understanding of the depth of the pool can undermine even the best intentioned DSM providers. Yogi Berra’s quote, “If you don’t know where you are going, you might end up somewhere else” could not be more applicable. Interdisciplinary cooperation in developing relationships with physicians and specialists whether they refer or not is instrumental and lies at the very heart of success for all parties concerned; especially since the dental sleep medicine practitioner cannot actually diagnose sleep disorders and cannot prescribe treatment for them. Information on records taking, comprehensive examinations and staging therapy are critical and useful to those who may still be using outdated forms that inadequately document the full scope of a patient’s health status and individual issues. The examination process is outlined with a state-of-the-art precision medicine technique to aid the dentist in making better therapy decisions while mitigating complications and issues that may come up legally later. The EHR, no longer far away on the horizon, is explained in detail with sound caveat emptor advice regarding computer programs, billing systems, etc. to keep providers from falling into a financial pit when getting their program up to speed. Practical matters such as treatment decision making and appliance selection are handled comprehensively, listing pros and cons of many temporary and permanent appliances without bias, as many providers really

NEW from Quintessence Ken Berley and Steve Carstensen This book is the how-to guide, a gateway to a successful dental sleep medicine practice. Written by two experts in the field, it clearly delineates the dentist’s role in the treatment of sleep-related breathing disorders and gives practical advice for how to incorporate dental sleep medicine into an existing dental practice. 240 pp (softcover); 60 illus; ©2019; ISBN 978-0-86715-813-7 (B8137); US $72

Contents

Read more about this book in our feature article “Obstructive Sleep Apnea: A Deadly Disease with a Dental Solution” on the Quintessence Publishing Blog at www.quintpub.net/news!

1. Clinical Guide for the Practice of Dental Sleep Medicine 2. An Overview of Sleep & Sleep Disorders 3. Dental Sleep Medicine Protocol and Practice 4. Integrating Dental Sleep Medicine into Your Practice 5. Treatment Decisions and Appliance Selection 6. Delivery of a Custom MAD 7. Complications of Oral Appliance Therapy 8. Evaluating Therapy and Ongoing Care 9. The New Reality 10. Legal Issues Related to the Practice of Dental Sleep Medicine 11. Medical Insurance and Medicare 12. Pediatric Airway Problems

CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere) 4/19 FAX: (630) 736-3633 EMAIL: service@quintbook.com WEB: www.quintpub.com QUINTESSENCE PUBLISHING CO INC, 411 N Raddant Rd, Batavia, IL 60510

BOOKreview don’t understand why one appliance may be better for a patient than another. Fabrication, delivery, follow up, compliance and complication issues are soundly outlined with emphasis on collaboration between dentist and medical providers to serve the patients’ best interests as treatment progresses. Legal issues and policy statements are fully reviewed by Dr. Berley who gives sage Pat Mc Bride, MA, RDA, CCSH, has spent 38 years as a full time clinician, educator and author in the fields of dentistry, respiratory medicine and dental sleep medicine. Her extensive experience in clinical, laboratory, research and educational arenas has led to the development of interdisciplinary care model delivery systems used in collaboration by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. In addition to writing and teaching, she is currently a Clinical Field Specialist for hypoglossal stimulator implant surgery for OSA. Serving the underserved and marginalized patient remains a passion and priority for her. She is a Ph.D. candidate at Fielding Graduate University while sitting on numerous Boards such as the AAPMD and NAAFO. She has one grown daughter who shares her passion for social justice and education, serving as a fifth grade teacher in the inner city Oakland.

advice coupled with a strong dose of what’s what in the current and future legal landscape of the profession. Some of this detailed information may be a real eye opener to many to folks who thought a turn key operation managed by others without MD involvement was strictly within the standard of care and practice guidelines. Many of the updated policies and insurance guidelines presented may find providers unaware. For example, the requirement that DME providers must carry an insurance Surety Bond as mandated by Medicare. Failure to have this in place could mean disaster for a practice that cares for many Medicare patients. These 210 pages are not meant to be “blown” through. This is a Bible, go out and buy it, highlight sections and then make up your own action items. Dog ear pages or whatever works for you so that it becomes the hub of your wheel. Then, refer to it again and again as you raise the level of your craft and improve the lives of your patients. We’ve all waited for a long time for a solid, practical and well written guide for the dental sleep medicine practice. Now we have it. There are no more excuses not to get it right from here on out.

Dental Sleep Practice 3 REASONS TO SUBSCRIBE • 8 CE credits available per year • 1 subscription, 2 formats – print and digital • 4 high-quality, clinically focused issues per year

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3 SIMPLE WAYS TO SUBSCRIBE • Visit www.dentalsleeppractice.com • Email subscriptions@medmarkmedia.com • Call 1-866-579-9496

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BEHAVIORALtherapy

Five Reasons to Consider Taping Your Mouth at Night by Paul A. Henny, DDS

e all breathe through our mouth part of the time. This is because mouth-breathing is necessary when we are exercising, working strenuously, under threat, or have a cold or sinus infection. These brief periods of mouth-breathing help us adjust oxygen flow to our body during periods of stress and challenge. This represents a proper use of our upper airway. At all other times however, mouth-breathing represents a dysfunctional use of our upper airway. In other words, when we use our mouth for breathing repeatedly and for extended periods of time, we are using it for a purpose that was never intended. This dysfunctional use of the upper airway causes maladaptive responses which have negative health implications. For example, many of us are mouthbreathers part of the time, while we sleep. We initially lie down with open nasal passages and breathe comfortably through our noses. However, as the night progresses, nasal tissues swell while throat muscles simultaneously relax. This causes our relatively small airway to become more constricted. Blood oxygen and CO2 levels drop, triggering the brain into a “fight or flight” response through the influence of adrenalin and cortisol release. The adrenalin then awakens us enough to open the airway wider, and we subconsciously switch to mouth-breathing to

further increase air volume. Consequently, a chronic and unhealthy sleep pattern is established: Increased Nasal Congestion > Mouth Breathing > More Adrenalin > Awakening = Poor Sleep Quality Mouth breathing in this fashion is dysfunctional, therefore nose-breathing throughout the night should be the end-goal if at all possible. If this scenario sounds familiar to you, one possible way to transition back into becoming primarily a nose breather at night is through the seemingly odd practice of “mouth-taping.” Mouth-taping is a way to encourage our body to increase our nasal air volume through more consistent use. The nasal passages are much like our muscle mass: it is a “use it or lose it” system. The more we use our nasal airway, the more it expands, and the more efficient it becomes at moving air (unless it is physically obstructed by polyps, a deviated septum, etc.)

Below are Five Reasons Why NoseBreathing is Critically Important to Health 1. Once transitioned to full nose-breathing, you will immediately realize deeper, more restful, sleep, often with less snoring. When we breathe through our nose effectively and efficiently, our heart rate DentalSleepPractice.com

BEHAVIORALtherapy

Mouth breathing is dysfunctional, therefore nose-breathing throughout the night should be the end-goal.

decreases as the amount of adrenaline in our body declines. (If you have ever woken up in the middle of the night with your heart racing, you know what I am referring to here). A full night of nose-breathing will improve the oxygen level in your blood and reduce the amount of “brain fog” you experience in the morning. 2. The nose is intended to warm, filter, and moisturize the air before it hits the throat and lungs. When we breathe through our mouths, the air hitting the back of our throat is cold, dry, and full of environmental contaminants such as allergens. To protect us from this unfiltered, dry air, the nasal passages over-compensate by excreting more mucus down the back of throat (“postnasal drip”). This in turn, causes congestion in the nose, which further impairs our ability to breathe through the nose, which leads to more mouth breathing! This self-perpetuating cycle can last a lifetime if not addressed. 3. Mouth-breathing changes the pH of our mouth and the types of bacteria in the altered oral environment. A dry mouth with this different bacterial composition is then much more prone to dental decay, gingivitis, and periodontal disease. Common side effects include chronic bad breath, bleeding gums, frequent cavities, sensitive teeth, and shifting and loosening teeth. 4. The brainstem interprets chronic mouthbreathing to be a “fight or flight” situation. In response, other parts of the brain signal to the adrenal glands to secrete more adrenalin to assist with the emergency. This causes us to awaken multiple times during the night and still feel exhausted in the morning. (Sleep apnea – where you actually stop breathing for extended periods of time, can cause this same outcome) By shifting your breathing to nose-only breathing at night, you will

Paul A. Henny, DDS is a graduate of the University of Michigan School of Dentistry, and has held adjunct faculty positions at the University of Kentucky, and at The Pankey Institute. He is a co-founder of the Bob Barkley Study Club, Managing Editor of CoDiscovery. com , and practices full time in Roanoke, Virginia.

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discover that you feel less anxious upon waking and on through the morning. Mouth-breathing is a dysfunctional form of “over-breathing.” 5. Nitric oxide is a molecule created and released in many parts of the body which influences our strength, endurance, blood pressure, level of arterial inflammation, sleep quality, sexual functions, and memory. Nitric oxide produced and released by cells lining our sinuses and released into the air we breathe through our nose has critical impact on respiration, which controls our blood oxygen levels. Air taken in by mouth breathing contains almost no nitric oxide.

How to Tape Your Mouth to Enhance Nose-Breathing

1. Purchase some 3M micropore surgical tape 2" wide from the drug store or Amazon. This tape is thin, white, paper-based, and semi-transparent. (Some prefer 1" wide tape) 2. Use nasal irrigation with a mild saline solution using sterile water, and blow / clear your nose / use nasal spray if needed. (NeilMed’s Sinus Rinse, Xlear nasal spray, and Breathe Right Nasal strips may be helpful in the beginning) 3. Apply a very light amount of edible oil such as olive oil or coconut oil to the area of the lips and skin where the tape will be in contact. 4. Tear off 3-4 inches of tape and fold the ends under slightly to create easy “tear off handles,” in case you need to cough or say, “good night.” 5. Put your lips together and puff them out a bit to create a little room for comfortable movement while asleep. 6. Gently compress the tape horizontally over your lips and onto the surrounding skin. If the idea of taping your mouth closed makes you anxious, it’s best to start out while awake in the evening before you go to bed. By telling yourself that you can, indeed, breathe just fine through your nose, you assure your subconscious brain that it’s safe. You can also try partial taping of your mouth by using the tape vertically (leaving the corners of your mouth un-taped) for a few nights until you get accustomed to the feel of the tape and your nasal passages have expanded.

NUTRITION

“An Apple A Day” by Julia Worrall, RN

hat old Welsh proverb “An apple a day keeps the doctor away” rings truer than ever today.

More than just a nutrient rich source of vitamins and fiber, an apple a day has the ability to reduce the risk of deadly diseases and improve one’s overall health for a lifetime. Wow. That’s quite a claim! Let’s consider some of the evidence…

The ABCs (and More) of Apples

This “miracle fruit,” as it was dubbed by a Florida State University biology study, is a source of vitamin C, B-complex vitamins, antioxidants, phytonutrients, flavonoids, and dietary fiber. Antioxidants and phytonutrients help protect the body against free radicals, which are believed to cause cancer. Free radicals are unpaired electrons that act like scavengers in the body. Dr. Lauri Wright, professor at the University of South Florida, describes them as “waste products from various chemical reactions in the cell that, when built up, harm the cells of the body.” Dietary fiber promotes movement of material through the digestive system and increases stool bulk. It also helps lower cholesterol and blood sugar levels. Another benefit of antioxidants and fiber is the increase in growth of the “friendly gut bacteria,” as it’s been called by Giuliana Noratto of the School of Food Science at Washington State University. Her team discovered that compounds in apples, especially Granny Smith apples, are fermented in the colon. The fermentation produces butyric acid, which spurs on healthy gut bacteria growth. It’s important to eat the peel of the apple, as that’s where much of the fiber and antioxidants are contained, according to University of California Davis (UCD) Department of Internal Medicine Dr. Dianne Hyson. The peel also acts like a broom on the intestines, scrubbing it clean of unwanted materials. Apples have the additional benefit of improving brain health. A study by the UCD Health System published findings that quercetin, one of the prevalent antioxidants in apples, was one of two compounds that helped protect cells from death caused by oxidation

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and inflammation of neurons. Another study by a conglomeration of Korean universities discovered that apple antioxidants reducedneuronal cell membrane damage, helping in turn to protect the brain against neurodegenerative disease. Through their nutrient-rich compilation, apples have also been shown to reduce the risk of diabetes, cancer, hypertension, heart disease, and stroke.

Did you know?

The simple act of chewing an apple a day helps develop proper facial structure! And that means promoting an optimal airway...which enhances proper breathing throughout the day as well as during the night while you sleep. In fact, the benefits of actually chewing an apple cannot be overstated! Through the act of chewing, the tongue is strengthened and the function becomes more coordinated. The muscle movement and bolus formation of the tongue contributes to proper facial growth and development. This in turn optimizes airway function, which directly affects one’s ability to breathe well during the day as well as during sleep. Which is why baby-led weaning, the process of moving from breastfeeding to (healthy) table meals without using pureed and bottled baby foods, is strongly recommended. Chewing on solid substances, like an apple, exercises the muscles, develops the maxilla and mandible, strengthens the jaw and promotes proper function of the temporomandibular joint. The chewing motion helps the baby’s face develop down and out. As the jaw matures fully, it allows space for the teeth and the development of an open airway, promoting unrestricted breathing. An underdeveloped jaw can lead to a smaller airway which restricts optimal breathing. We call this an Airway Centered Disorder (ACD). ACD’s can cause very serious health consequences such as sleep apnea, ADHD, anxiety, depression, endocrine and cardiovascular diseases. Small choices, made everyday, can

NUTRITION lead to a lifetime of health, or disability for your child.

A Great Smile

Dental caries is rampant in our society. Parents are advised to minimize sugar intake. So what about the sugars found in apples? Xylitol is naturally occurring in most plant material, including, you got it – apples! Xylitol has been shown through several studies to have an inhibitive effect on both acid production in the mouth and formation of new oral biofilms. A biofilm is a secretion of stringy sugars, proteins, and DNA fragments into what becomes a protective coating around the bacteria. In the mouth, it manifests itself as dental plaque. Xylitol exerts its powerful, anti-cariogenic effects against biofilms of harmful bacteria through what Hoffman Center Medical Director Dr. Ronald Hoffman called a “Trojanhorse mechanism.” He explained that xylitol causes the biofilms to auto-destruct by masquerading itself in the microbial fructose phosphotransferase system. It then interferes with carbohydrate metabolism and inhibits bacterial growth of those biofilms. So by eating apples, one receives the added benefit of biofilm penetration and a reduc-

tion in decay-causing bacteria in the saliva as well as a reduction in the bacteria that can lead to ear infections. That’s a win-win!

A Prescription for Health

Between the multiple nutritious compounds and fiber it contains, the biofilm reduction and the facial development it encourages, the humble apple is truly a dynamic force contributing to lifetime of health. An apple a day, it turns out, can quite literally, keep the doctor away!

Julia Worrall, RN, is the Program Director for the Airway Advocate Program. This is an initiative of The Foundation for Airway Health which is a coalition of medical, dental, and allied healthcare providers dedicated to combating airway-related disorders. The mission of their 15-50-20 campaign is to take the 15 percent public awareness of this problem to a 50 percent national recognition and treatment of airway disorders by 2020. Part of the Foundation’s campaign is being accomplished through Airway Advocate Workshops. The Foundation hosts these hands-on intensives across the country in an effort to empower change agents in the world of modern healthcare. In-depth training is offered regarding best methods for airway and sleep management, from screening to treatment. Register or learn more at www.airwayhealth.org.

Dental Sleep Practice is honored again... to have been chosen to sponsor the Sleep Apnea Symposium at the Greater New York Dental Meeting, Nov. 29-Dec. 4, 2019 Dental Sleep Practice will sponsor lectures each day from Sunday, December 1 through Wednesday, December 4. Watch for more details at:

www.GNYDM.com

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COMORBIDITIES

Sleep and the Growing and Going Problem by Warren Schlott, DDS

PROBLEM

ne of the most common complaints of men who sleep poorly is that they have an urge or a need to use the restroom many times during the night. This can lead to sleep fragmentation and excessive daytime sleepiness. Most often the cause is an enlarged prostate, also known as benign prostatic hyperplasia (BPH). While this condition is most often treated by an urologist, the sleep dentist should be aware of this condition as treating underlying sleep apnea may help the patient sleep better.

BPH is a condition in which the prostate gland enlarges and squeezes or blocks the urethra.1 The enlargement is not due to cancer. The prostate gland is a walnut-shaped gland that surrounds the urethra at the neck of the bladder, where the urethra connects. The prostate gland grows during two phases in a man’s life. At birth, it is about the size of a pea. At puberty the first growth phase doubles its volume. The second phase of growth begins around the age of 25 and continues most of a man’s life. There are two theories that may explain prostate growth.2 As men age, the total amount of active testosterone in their blood falls, which leaves a higher ratio of estrogen in the prostate. Studies have suggested that a higher proportion of estrogen increases the activity of substances that promote prostate cell growth. Another theory targets dihydrotestosterone (DHT) as the culprit in prostate growth. Research

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has shown that even with testosterone levels dropping, men continue to produce and accumulate high levels of DHT. It is thought that the accumulation of DHT encourages prostate growth. It has been found that men who do not produce DHT do not develop BPH. Regardless of the cause, benign prostatic hyperplasia is a common problem. BPH is most common in men over the age of 50. Research suggests that up to 14 million men in 2010 had symptoms suggestive of BPH.3 Other studies indicate that 50% of men between the ages of 51 and 60 and up to 90% of men older than 80 have BPH.4 It appears that the risk factors for developing BPH include aging and a family history of the condition. Some have suggested that obesity, heart and circulatory disease, and type 2 diabetes, and erectile dysfunction can be additional risk factors. The “growing and going problem” can make life more difficult. As the prostate enlarges, it pinches the urethra. This results in the bladder wall becoming thicker. Eventually, the bladder can weaken from trying to push urine through the blockage and lose the ability to completely empty itself. Symptoms can include urinary frequency (urination eight or more times a day), the inability to delay urination, trouble starting a urine stream, a weak or interrupted urine stream, dribbling at the end of urination, urinary incontinence (accidental loss of urine), pain during urination, a sense that the bladder is not empty, and nocturia.5 It rarely

COMORBIDITIES causes serious complications, but it can be bothersome and embarrassing. Treatment for BPH includes lifestyle changes, medications and surgery.6 Symptoms of mild BPH can often be mitigated by reducing fluid intake before going out in public or before sleep. Avoiding or reducing alcohol and caffeinated beverages may be beneficial. Reducing medications such as decongestants, antihistamines, antidepressants, and diuretics is often recommended. Finally exercising pelvic floor muscles can help mild symptoms. If lifestyle changes are insufficient to manage symptoms, medications can be used. There are three types of drugs used to treat BPH. The most common medications used are alpha blockers. These drugs relax smooth muscles of the prostate and bladder to improve urine flow. Examples of this type of drug include Flomax, Uroxatral, Hytrin, Cardura, and Rapaflo. For the significantly enlarged prostates, 5-alpha-reductase inhibitors are used. These drugs block the conversion of testosterone to dihydrotestosterone and may actually shrink enlarged prostates. Proscar, Avodart, and Jalyn are examples. The third type of drug used is phosphodiestrase-5 inhibitors. More commonly used for erectile dysfunction, these drugs can reduce symptoms of BPH by relaxing smooth muscles of the urinary tract. Cialis is an example of this family of drugs. Even though any of these drugs can have significant side effects, they are the most popular choice of treatment. Surgery is the only other treatment option. Surgical options can be minimally invasive or invasive.7 Minimally invasive procedures can include needle ablation, microwave thermotherapy, high intensity focused ultra sound, and electrovaporization. These surgical approaches can destroy prostate tissue or widen the urethra to relieve blockage. Minimally invasive procedures can relieve BPH symptoms, but there is a risk that symptoms may return as the prostate continues to grow. Side effects from the surgery can be significant. The most common invasive surgery is known as TURP, transurethral resection of the prostate. This procedure involves uses a wire loop to remove enlarged tissue. TURP is considered the gold standard for treating blockages due to BPH. However, side effects including sexual dysfunction are

common. Which treatment, or combination of treatments, that is best for the patient is decided by the urologist and patient. Treating comorbid sleep apnea may help. BPH patients become creatures of habit. They generally know the location of nearby restrooms and take advantage of them regardless of the urge to urinate. Restroom use becomes insurance against the uncontrollable urge to urinate. In other words, restrooms are used whether there is an immediate need or not. It is well known that patients can be wakened by arousals caused by among other things apneas, hypopneas, and airway resistance. If a BPH patient is wakened by arousal, he is most likely to use the restroom even if there is not an extreme urge. By eliminating the arousals, the BPH patient may be capable of sleeping longer without the need of restroom use. It is the author’s opinion the most BPH patients have arousals primarily during REM sleep and eliminating these arousals provides an invaluable service to the patient. Treating the arousals will not cure BPH, but it can help improve sleep quality, making his world a better place. BPH patients who have not discussed their possible condition with a physician, and who have mentioned the frequent need to urinate during sleeping hours to the sleep dentist, should be referred to a physician, usually an urologist, for a diagnosis and treatment. Treatment of a diagnosed sleep disorder can help the patient. 1. 2. 3. 4. 5. 6. 7.

The sleep dentist should be aware of BPH – treating underlying sleep apnea may help the patient sleep better.

www.auanet.org American urological Association www.auanet.org American Urological Association Deters LA. Benign Prostatic Hypertrophy Emedicine website. http://emedicine.medscape.com/article/437359 overview BPH: Surgical Management. Urology Care Foundation website. www.urologyhealth.org/urologvy/index.cfm? article=31 Roehrborn CG. Male Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH) Med Clin North Am. 2011 Jan95(1):87-100 Auffenburg GB, helfand BT, McVary, KT. Established Medical Therapy for Benign Hyperplasia Urol clin North Am 2009 Nov:36(4)443-59 McVary KT, roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al. Update on AUA Guideline on the Management of Benign Prostatic Hyperplasia. J Urol. 2011 May: 185(5):1793-803 Epub 2011 Mar 21

Warren J. Schlott has been a practicing dentist in Brea, California since 1978. Dr. Schlott developed a thriving restorative dental practice and then in the early 2000’s developed a busy full time sleep practice. He has published numerous articles, and has helped other dentists establish sleep practices. Dr. Schlott is a member of the American Academy of Sleep medicine and is a Diplomate of the American Academy of Dental Sleep medicine. Dr. Schlott can be reached at wschlott@wschlott.com.

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LEGALledger

Home Sleep Apnea Testing and Dental Sleep Medicine by Jayme R. Matchinski, Esq.

s the provision of Dental Sleep Medicine continues to evolve and expand, dentists are faced with the challenge of how to incorporate home sleep apnea testing (HSAT) into the care and treatment of their patients who may have obstructive sleep apnea (OSA) and require Oral Appliance Therapy (OAT). HSAT has changed the provision of Polysomnography from the traditional setting of providing an in-lab attended sleep study at a sleep disorder center to the utilization of HSAT, as a portable device which is a sleep study tool that can be provided to a patient in their home, and is an unattended sleep study that tracks a patient’s breathing, oxygen levels, and breathing effort while wearing the HSAT device. I am often asked by dentists how they can utilize HSAT in their practices and how they can work with DME companies and sleep physicians for the provision of HSAT. There has been a lot of discussion and questions regarding whether dentists can order HSATs and provide HSATs free of charge to their patients. Dentists have also sought to contract with companies which provide HSAT. Dentists should not seek to circumvent the involvement of a sleep physician in the examination, referral, diagnosis, and treatment of a patient with OSA or other sleep disorder. Dentists and sleep physicians should seek to work together to develop protocols for the usage of HSAT and provision of OAT.

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Licensure and Regulatory Compliance

Dentists should check their state licensure and third party payor agreements regarding whether they can prescribe HSAT. While sleep testing companies are encouraging dentists to provide HSATs to their patients for the screening and diagnosis of OSA, this may be outside a dentist’s scope of practice depending upon state licensure. Additionally, certain third party payors, including the Center for Medicare & Medicaid (CMS), require a licensed sleep physician to prescribe an HSAT and interpret the results from the HSAT. Dentists should consider setting up protocols and agreements with referring physician, including sleep physicians, in order to identify each doctor’s responsibilities for the sleep testing, diagnosis and treatment of a patient with OSA. Dentists should be careful not practice outside their scope of practice and state licensure. CMS will not pay any DME supplier, including dentists and sleep physicians, for the provision of CPAP if that DME supplier or its affiliate, is the provider of the sleep test, either directly or indirectly, and the sleep test is used to diagnose the Medicare patient or any patient who has coverage pursuant to a federal or state program, unless the sleep test is provided in an attended facility-based polysomnogram. “No Medicare payment will be made to the supplier of a CPAP device if that supplier, or its affiliate, is directly or indirectly the provider of the sleep test used to diagnose the beneficiary with obstructive sleep apnea.

For the treatment of

Features

Obstructive Sleep Apnea and Snoring

• Minimal vertical clearance • Trains the tongue to stay forward • Available in 90° and locking 110° variation • Sleek design for complete patient comfort • Dual appliance system for both Sleep and TMD • Treat OSA, associated breathing symptoms, and snoring • Patented dorsal design withstands bruxing and clenching • Decreases frequency and duration of apneic and hypopneic event

For more information on this life changing appliance 4545 Sweetwater Blvd. Sugar Land, Texas 77479 o: 281/565-4100 www.meridianpm.us

LEGALledger This prohibition does not apply if the sleep test is an attended facility-based polysomnogram.” (42 CFR §424.57(f)). For purposes of this regulation, “affiliate” means “a person or organization that is related to another person or organization through a compensation arrangement or ownership.” (42 CFR §424.57 (a)). “Attended facility-based polysomnogram” means “a comprehensive diagnostic sleep test including at least electroencephalography, electrooculography, electromyography, heart rate or electrocardiography, airflow, breathing effort, and arterial oxDentists and sleep ygen saturation furnished in a sleep labphysicians should seek oratory facility in which a technologist supervises the recording during sleep to work together to time and has the ability to intervene if develop protocols for needed.” (42 CFR §424.57 (a)). If a provider combines functions of a sleep lab the usage of HSAT and DME services and the provider has and provision of OAT. Medicare provider and supplier numbers for the sleep lab and DME supplier, under 42 CFR §424.57(f), the DME supplier will not receive Medicare, Medicaid, CHAMPUS, TriCare, or any other government program reimbursement for the CPAP unless the sleep test is an attended facility-based polysomnogram which includes Level 1 sleep testing. This federal regulation prohibits Medicare reimbursement for CPAP to a DME supplier if the sleep test is HSAT and the HSAT is provided by an affiliate of the DME supplier; however, there has been discussion regarding the expansion of this regulation to include OAT as the prohibited DME if the DME supplier or its affiliate is the provider of the sleep study. To date, these federal regulations specifically identify CPAP as the DME that will not be reimbursed if the DME supplier or its affiliate is the provider of the sleep test, and this federal regulation has not been revised to include OAT. Dentists, sleep physicians, DME suppli-

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

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ers need to continue to monitor this federal regulation in the event that it is revised in the future to include OAT as the DME. CMS promulgated this federal regulation to monitor the utilization of HSAT and to discourage referrals between affiliated sleep labs and DME suppliers which have a compensation arrangement or ownership. Based upon this regulation, DME suppliers will not receive reimbursement for the DME, specifically CPAP, that is prescribed based upon a diagnosis of OSA if the sleep test was an HSAT or not provided in an attended facility-based by an affiliate of the DME supplier.

Provision of HSAT

There have been a lot of questions posed by dentists regarding who can refer a patient for a sleep study, including a HSAT. In general, a “referral” is a sleep physician’s request for, ordering of (or certifying or recertifying the need for), any diagnostic testing or services for Medicare patients, including a consultation request and tests or procedures ordered, performed or supervised by the consulting physician or the physician’s request or establishment of a plan of care involving Medicare designated health services pursuant to the Stark Law regulations. In addition, a physician who directs or controls referrals by others is deemed to be a “referring physician”. For Medicare patients, a physician is required to write an order for a sleep study. Many commercial insurance companies have adopted the Medicare regulations and coverage guidelines for HSAT and provision of DME. Dentists should carefully review their third party payor agreements with commercial insurance companies to determine the qualifications and licensure that are required by the payor agreement for the provision of sleep studies and OAT.

HSAT Agreements and Regulatory Compliance

I am often asked how dentists can work with HSAT companies which provide the equipment, scoring, and billing related to the provision of HSAT to patients. Dentists should have a written agreement with the HSAT company and/or the sleep physicians who are prescribing, diagnosing, and interpreting the results of the HSAT. Dentists should consider including provisions in agreements for HSAT which specifically state which services will be

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LEGALledger provided, including the equipment, scoring, and billing related to the provision of HSAT. There should also be a provision in the HSAT agreement which identifies who is responsible for the documentation of the provision of the HSAT and retention of such documentation. There are state and federal regulations regarding what information is required to be included in a patient’s medical record and how long such medical records must be retained by the provider. Some DME companies and providers, including dentists, have sought to provide HSAT free of charge to patients in order to facilitate the provision of OAT. This practice may be in violation of the applicable state and federal anti-kickback regulation. Each state has anti-kickback regulations which generally prohibit payment or an arrangement between providers which would induce patient referrals which are prohibited by state law. There is a federal Anti-Kickback Statute which applies to any arrangement for the provision of services to Medicare patients or other government beneficiaries. 42 U.S.C. § 1320a-7B, commonly known as the Medicare Anti-Kickback Statute, states that is a felony for a person or entity to knowingly or willfully offer or pay any remuneration to induce a person to refer a person for the furnishing or arranging for the furnishing of any item for which payment may be made under a federal health care program, including the Medicare and Medicaid programs, or the purchase or lease or the recommendation of the purchase or lease of any

Dental Sleep Medicine is an evolving area of health care and the regulations continue to change and expand.

68 DSP | Summer 2019

item for which payment may be made under a federal health care program, including HSAT and OAT. Health care providers and suppliers cannot offer or pay any remuneration to induce referrals between providers and other entities, including any arrangements that directly or indirectly base compensation upon volume or value of such patient referrals. There have been cases and Advisory Opinions by the Office of Inspector General (OIG) which have indicated that offering rental space, equipment, staff, and ambulance services and related supplies without charge to providers and patients is a violation of the federal Medicare Anti-Kickback Statute because it is an inducement for patient referrals by and between health care providers and entities. Any compensation arrangements, including payment for services, by and between dentists, sleep physicians, DME companies, and sleep labs cannot be based upon any volume or value of patient referrals between the parties. Additionally, dentists and sleep physicians must consider the impact of the Stark Law on any arrangements for the provision of HSAT and OAT if Medicare or any other government patients are involved. 2 U.S.C. § 1395nn, known as the Stark Law (Ethics in Patient Referral Act), prohibits physicians from referring Medicare patients for “designated health services” (“DHS”) to any facility or other entity with which the referring physician (or any of his or her immediate family members) has any financial relationship, unless an exception in the Stark Law or related regulations is satisfied. Furthermore, the entity providing the DHS would be prohibited from billing Medicare for the services. The original Stark Law (Stark I) applied only to Medicare referrals for clinical laboratory services. Stark II, enacted in August 1993, expanded the prohibition to apply to an additional list of DHS and to referrals to Medicaid as well as Medicare patients. While the actual sleep study, including HSAT, is not considered a DHS for purposes of the Stark Law, DME, including OAT, is a DHS and dentists and sleep physicians must consider the impact of the Stark Law on the provision of OAT to Medicare and Medicaid patients or any other government beneficiaries. Under Stark I and Stark II, prohibited financial relationships include: ownership or investment interests through equity, debt or other means and include indirect ownership interests through other entities, as

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LEGALledger well as compensation arrangements including virtually any form of remuneration. Possible sanctions for violation of the Stark Law include: civil monetary penalties, exclusion from the federal health care programs (including Medicare and Medicaid) and forfeiture of all improperly collected amounts.

The Medicare regulations define DME as:

§414.202 Definitions. Durable medical equipment means equipment, furnished by a supplier or a home health agency that meets the following conditions: (1) Can withstand repeated use. (2) Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years. (3) Is primarily and customarily used to serve a medical purpose. (4) Generally is not useful to an individual in the absence of an illness or injury. (5) Is appropriate for use in the home. (42 CFR § 414.202.) OAT meets the definition of DME for purposes of Medicare coverage, and Medicare will reimburse eighty percent (80%) of the expenses for the OAT if the OAT meets the following criteria: • The item is “durable medical equipment”. An item is covered only if it meets the statutory definition of durable medical equipment which is cited above; • The item is necessary and reasonable. DME, including OAT, is covered only if it is necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member. Equipment is necessary when it can be expected to make a reasonable contribution to the patient’s treatment. In most cases, a physician’s prescription for the equipment, along with other medical information available to the carrier, will establish medical necessity. However, it is important to note that even if an item serves a useful medical purpose, it will be covered only to the extent that it would be reasonable for the Medicare program to pay for the item prescribed; and • The item is appropriate for use in the home. The DMEPOS benefit is available only for items used in the beneficiary’s home, which can be a beneficiary’s own dwelling, an apartment, a

70 DSP | Summer 2019

relative’s home, a home for the aged, or some other type of institution. However, an institution cannot be considered a beneficiary’s home if it meets the basic definition of a hospital or skilled nursing facility. The provision of HSAT and OAT across state lines triggers state regulations, including scope of practice, in the states where the patient is purchasing the OAT. Each state has its own practice acts, including Dental Practice Acts, and scope of practice requirements. Given the changing regulatory landscape, dentists and sleep physicians need to carefully consider how they are providing professional services, diagnostic testing, including HSAT, and related OAT for the treatment of patients and their OSA. In summary, given the enforcement efforts by CMS and state licensing boards regarding compliance with the Anti-Kickback Statute, Stark Law, and the applicable state Dental Practice Act, dentists must structure their proposed arrangements with other providers, including sleep medicine physicians and physician group practices, for the provision of HSAT and OAT, in full compliance with the applicable regulations so as not to jeopardize the dentist’s licensure and enrollment with third party payors. Dentists should consider the following steps to ensure regulatory compliance for the provision of HSAT and OAT: • Comply with all applicable state and federal regulations for the provision of HSAT and OAT; • Consider requiring the utilization of a patient acknowledgment form that the patient will need to review and sign prior to receiving OAT. This patient acknowledgment form will require the patient to sign off that they have been given a choice as to where they receive their OAT and have decided to receive the OAT from the designated dentist. Dentists should retain this signed patient acknowledgment form in the patient record; and • Continue to monitor new regulations and CMS and State Licensing Board’s enforcement efforts, investigations, and audits regarding the provision of HSAT and DME, including OAT, as Dental Sleep Medicine is an evolving area of health care and the regulations continue to change and expand.

SEEKandSLEEP

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Unscramble key words from this issue.

soniamni __ __ __ __ __ __ __ __ stigenncoo __ __ __ __ __ __ __ __ __ __ syliepep __ __ __ __ __ __ __ __ aroosalmircus __ __ __ __ __ __ __ __ __ __ __ __ __ aprroommiantedlbu __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ loupinopat __ __ __ __ __ __ __ __ __ __ aimidnoisssg __ __ __ __ __ __ __ __ __ __ __ __ frymceeton __ __ __ __ __ __ __ __ __ __ ginndabr __ __ __ __ __ __ __ __ pealp __ __ __ __ __ nesteerbrimmu __ __ __ __ __ __ __ __ __ __ __ __ __ emeinletdice __ __ __ __ __ __ __ __ __ __ __ __ slwelnse __ __ __ __ __ __ __ __ shrbte __ __ __ __ __ __

For the solution, visit www.dentalsleeppractice.com.

72 DSP | Summer 2019

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