Dental Sleep Practice Summer 2020 by MedMark, LLC

Continuing Education

Telemedicine:

It's About Time

by Jagdeep Bijwadia, MD, MBA, D.ABDSM

ProSomnus' Next Quest...

by Mark T. Murphy, DDS, D.ABDSM, and Len Liptak, MBA

SUMMER 2020 | dentalsleeppractice.com

PLUS

COVID-19:

A Paradigm Shift for Treatment of SRBD Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Keith Thornton, DDS

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INTRODUCTION

Tragedy into Triumph

o, um, yeah, a lot has happened since the last issue of Dental Sleep Practice. As I write this, the COVID-19 pandemic continues to wreak havoc on the world bringing unprecedented illness, death, and economic hardship. Our cities, our communities, our nation, our lives, are in a state of unrest and upheaval. It has thrust a level of volatility upon the dental field that most of us have never experienced. The world is hurting. It can feel like our lives have become a dystopian sci-fi film – and we can’t find the remote to change channels. The pandemic has also opened the valves of innovation and generated an outpouring of generosity that are both inherent to the Dental Sleep Medicine community. We’ve witnessed numerous organizations adapt by shifting their top-notch continuing education to online platforms. We’ve seen several companies provide free oral appliances to essential workers. Others have pivoted to leverage their manufacturing capacities for the fabrication of protective gear for those on the front lines of this battle. We’ve also experienced increasingly widespread adoption of telemedicine which empowers DSM providers to help people sleep and breathe, and we’ve watched dental practices heroically manage emergency patients to mitigate strain on the healthcare system. What will the future of Dental Sleep Medicine look like? I don’t think any of us can say with a high degree of certainty. In many ways, our entire world is in a state of flux. The landscape will undoubtedly change between the time I write this and the time you read it. However, we each possess agency and we can control what we can control. During these days of trepidation, I’m reminded of the Stoic philosopher, Epictetus’s timeless maxim in which he stated, “In life our first job is this, to divide and distinguish things into two categories: externals I cannot control, but the choices I make with regard to them I do control. Where will I find good and bad? In me, in my choices.” Each of us can focus on what is in our locus of control. What skills do you need to further hone but couldn’t previously carve

out the required time? This could be Jason Tierney an opportune time to improve those skills through reading or online education. Are there systems or workflow that need improvement in your practice? Now is the prime time to map the strategies for future success. A time will come when you’ll be busy again and you won’t get this time back. We possess the power to arise from this tragedy stronger – as individuals, as caregivers, as a pro- We possess the power to fession, and as a nation. arise from this tragedy Despite all the uncertainty, there are some axioms: People stronger – as individuals, as must sleep to live. Quality of caregivers, as a profession, sleep directly impacts quality of life. You have helped save lives and as a nation. through improved sleep in the past. You will help with this in the future. While we don’t know precisely what changes are beyond the horizon or what “OK” will look like – we can each be 100% assured that everything will be OK. And to quote Bill Murray in Stripes, “That’s a fact, Jack!” Take care of yourselves and each other. Make it happen…

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing questions about the article “Telemedicine: It’s About Time” by Jagdeep Bijwadia, MD, MBA, D.ABDSM, which starts on page 38. The CE quiz can be submitted online at www.dentalsleeppractice.com or via mail. Sponsored by MedMark, LLC, and CE Zoom, LLC.

DentalSleepPractice.com

CONTENTS

Cover Story

ProSomnus’ Next Quest...

Practice Growth

9 Steps for Success

by Steve Carstensen, DDS, FAGD, FACD, FICD, D.ABDSM What if you had decades of DSM experience compiled into an actionable checklist for your future? Here it is.

by Mark T. Murphy, DDS, D.ABDSM, and Len Liptak, MBA

Most physicians cite 4 reasons they don’t Rx OAT. What are they and how can you counter them?

Pediatrics

The Future Face of Sleep by Sharon Moore What is “good” sleep? For kids? For adults?

Choosing Appliances

COVID-19: A Paradigm Shift for the Treatment for Sleep Related Breathing Disorders

by Keith Thornton, DDS The COVID-19 pandemic has put a spotlight on non-custom appliances. How can you model their use in your practice?

Continuing Education

Telemedicine: It’s About Time by Jagdeep Bijwadia, MD, MBA, D.ABDSM The COVID-19 pandemic has highlighted the importance of telemedicine. Get the background you need to harness this disruptive technology.

2 CE CREDITS

2 DSP | Summer 2020

With ProSomnus

Dentists can establish OAT as preferred therapy.

Recent surveys report sleep Physicians have legitimate concerns about traditional OAT. ProSomnus precision OAT devices are designed to address Physician barriers. “With ProSomnus Medical Devices, efficacy is not compromised with simplicity. Less protrusion, no moving parts and a company who listens, makes their devices a winner in the world of Dental Sleep Medicine.” —Dr. Kent Smith, DDS, D.ABDSM, D.ASBA

“ProSomnus is one of my go to appliances because I can depend on the consistency of the fit and its ease of use. My patients who have used other appliances in the past, often comment on how much less bulky ProSomnus feels and how much easier it is to keep clean.” —Dr. Brandon Hedgecock, DDS, D.ABDSM, D.ASBA

“ProSomnus precision engineered devices provide my patients with consistent results. ProSomnus devices are smaller, more comfortable and less porous.” —Dr. Srujal H. Shah, DDS, D.ABDSM Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness.

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Visit ProSomnus.com or call 844 537 5337 for a free starter kit.

844 537 5337 ProSomnus.com Leader in Precision OAT®

CONTENTS

Publisher’s Perspective

“It’s what you learn after you know it all that counts” by Lisa Moler, Founder/CEO, MedMark Media

16 Medical Insight

Why Use an Anterior Only Stop with Oral Appliance Therapy? by Barry Glassman, DMD, and Don Malizia, DDS When and why should you add an anterior midpoint stop to your oral appliances?

26 Product Spotlight

Teledentistry Brings HealthyStart Home by Brooke Stevens How can teledentistry help your pediatric patients and their parents sleep better?

28 Expert View

In Your Own Words We asked 6 Dental Sleep experts 3 questions about creating medical referral sources.

32 Practice Management

Medical Billing for Telemedicine for DSM by Rose Nierman, Founder & CEO, Nierman Practice Management Timely tips on telemedicine billing.

46 Billing Blocks

Is Unethical Billing Preventing Quality Sleep? by Randy Curran Who’s responsible for ensuring you’re billing properly? The answer may stun you.

48 Ortho Connection

Increasing airway volume with a removable orthodontic dental appliance: a multi-case report by Theodore R. Belfor, DDS, Michael Philcock, and Scott Simonetti, DDS Does OAT remodel the airway and increase muscle tone when the appliance isn’t being worn?

52 Product Spotlight

Pending Restorative Work But Need Oral Appliance Therapy? What do you do when your patient needs OAT now but is getting a crown next month?

54 Practical Tips You Shouldn’t Have to Adjust

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

Director of Operations Don Gardner | don@medmarkmedia.com Manager – Client Services/Sales Adrienne Good | agood@medmarkmedia.com

by Alexander T. Vaughan, DDS, MS, D.ABOP, and Michael S. Pagano, DDS, D.ABDSM Are minimum OAT standards really the best fit for your patients and practice?

Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com

56 Sleep Humor

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

...The Lighter Side of Sleep Apnea

Medical Insight

Should I add TMD care to my DSM practice?

by Jamison Spencer, DMD, MS Can adding TMD to your practice reduce strain on the healthcare system?

4 DSP | Summer 2020

Summer 2020

Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius | emedia@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 Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2020. 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.

PUBLISHER’Sperspective

“It’s what you learn after you know it all that counts”

uring this COVID-19 crisis, our learning curves have ramped up to high gear. We have learned so many things — about business, medicine, dentistry’s evolving needs, resilience, hope, and caring. Forward-looking leadership and a loyal team are attributes that MedMark has always cultivated, and all of us have turned our quarantines into positive action. As our world changes and as needs evolve, we have also sought insight from mentors whose experience can be life-changing and game-changing.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Summer 2020

“A mentor is someone who allows you to see the hope inside yourself. A mentor is someone who allows you to know that no matter how dark the night, in the morning joy will come. A mentor is someone who allows you to see the higher part of yourself when sometimes it becomes hidden to your own view.” These words by Oprah Winfrey are meaningful. After being a part of the dental world for 20 years, I have witnessed the phenomenal benefits of having and being a mentor. The journey to building a business can be frustrating and heartbreaking without someone to offer advice on the right paths to take and the hazards to avoid. I recently read an article from Inc. magazine describing why mentors are integral to success. John Rampton offered these top 10 reasons: 1. Mentors provide information and knowledge. 2. Mentors can point out where we need to improve. 3. Mentors stimulate our growth. 4. Mentors offer encouragement. 5. Mentors can help us self-discipline. 6. Mentors are open to listening to our ideas. 7. Mentors are trusted advisors. 8. Mentors can help with networking. 9. Mentors have experience you can learn from. 10. Mentors are free, but priceless.

MedMark Media brings the expertise of mentors and innovators in the dental community to your houses, offices, and computers. Over the years, dental mentors have helped our company grow from print magazines to digital formats, webinars, videos, and podcasts. If there is a way to reach you, we will be there! In this issue of Dental Sleep Practice, Dr. Mark Murphy and Len Liptak discuss cooperation between dental sleep medicine professionals and physicians regarding OAT referrals. In his CE, Dr. Jagdeep Bijwadia delves into telemedicine and making informed decisions about the implications of this evolving technology. Also regarding telemedicine, Dr. Keith Thornton writes about the possibility of patients effectively treating and managing their SRBD at home with a device such as the myTAP, while interfacing with their dental sleep professional. Mentors will help keep your protocols and knowledge fresh and exciting. So keep searching for those who can help you to achieve greatness. It’s never too late to have a mentor or to become one, since learning and sharing knowledge should happen in all stages of life. As President Harry S. Truman said, “It’s what you learn after you know it all that counts.” To all of our readers, authors, and advertisers, we wish you all health, safety, and a speedy resolution to the COVID-19 crisis. To your best success!

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PRACTICEgrowth

9 Steps for Success by Steve Carstensen, DDS, FAGD, FACD, FICD, D.ABDSM

ave you ever been asked to do something you weren’t trained to do? Did you feel some pressure, either from the requester or in your own mind, to say “Yes” because you “should” know what to do, but, really, it would require stepping outside your limits? This nearly universal experience in our dental offices defines “Scope of Practice.” It’s all about what you are trained to do.

The definition of what we are legally allowed to do lies within our individual state’s dental practice act. Nearly every state has included the American Dental Association’s definition of dentistry. In part, that description states: Dentistry is defined as the evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law. (Adopted by the 1997 ADA House of Delegates)

8 DSP | Summer 2020

As airway therapists, this definition allows us to expand our scope of practice with education and professional collaboration to treat problems in the nasal airway and oropharynx as we consider the impact of sleep related breathing disorders (SRBD) on the human body. Taking a position that dentists can do more to help their airway-compromised patients than simply providing mandibular advancement devices implies the need to understand what you are treating and the critically important fact that, as a dentist, you are not equipped to diagnose many diseases in those adjacent and associated structures. Nothing, however, prohibits the trained dentist from helping their patients become better nose-breathers, for example. If dentists are the chief providers of oral health care, and physicians of general medicine, where does the ethical and conscientious dentist place their practice along this continuum? How aggressively towards medicine can we move? Currently, the dividing line falls at the diagnosis of obstructive sleep apnea – dentists are not licensed to make that determination. On the other hand, dentists are expected to be effective therapists for patients referred by diagnosing physicians – and the ADA backs up the ‘effective’ bit by

PRACTICEgrowth endorsing our use of objective monitors for measuring response States are being asked to rule on which monitors fall within the licensure of dentists – while most states have made no ruling, a few have proscribed the use of home sleep apnea testing devices. Meanwhile, millions of Americans suffer from SRBD and there has been no significant progress in addressing this large population during the time treatment has been available. Consumer sleep technologies will soon provide every bit of data necessary to assess sleep breathing and physiologic responses; the medical profession has to decide if it is going to keep its expert position or yield it to Apple, BEDDR, Withings, or some other commercial technology entity. There is no better time for dentists to become the most important part of community health by guiding our patients into proper diagnosis and providing effective therapy to help them breathe. What can you, as a dental team, do now to make a difference and position yourself for the near future? There are nine good steps to take: 1. Reflect on your motivations, goals, vision, and office culture and make a decision about whether treating SRBD fits. 2. Optimize your team. Effective therapy only happens with a well-trained team operating efficient systems. The financial rewards can be great if you efficiently leverage your team and minimize doctor time. 3. Screen every patient. This will yield surprising results if you didn’t previously include airway-related questions on your health history. 4. Master the use of non-sleep-test objective monitors. High resolution oximetry devices have been used in medicine for many years and this is not license-risky for dentists. Add cardiopulmonary coupling and effects on physiology come sharply into focus. 5. Know your limitations. There is no sharp dividing line between ‘Dental Health’ and ‘Health’ but physicians, nurses, and medical assistants are trained to assess data most dentists are not. 6. Expand your scope through valid education. Be cautious of offerings that focus on increasing income, require a

big ‘buy-in,’ or tout only one therapy choice. Scientific knowledge is rapidly accumulating. Keep learning. 7. Build a coalition in your community of other professionals and create mutual trust by focusing solely on optimum patient outcomes, no matter which therapy is deployed. Airway problems are rarely solved by one provider. 8. Follow your patients. Oral appliance therapy is a means of managing chronic disease. Diagnosis and treatment of SRBD is undergoing rapid change; staying abreast of new developments and your patients’ progress are parts of a professional’s commitment. 9. Accept patient autonomy. Even patients who successfully manage their airway with your therapy might make another choice from time to time. Focus on what works for them; maintaining a trusting relationship will allow them to ask for your help again when they feel the need. Readers of Dental Sleep Practice won’t be surprised by any of these steps. If the first question that comes to you is ‘How do I do that?’ congratulations, you are a seeker of knowledge – find a great education program and create your action plan. You may already be enjoying the position of ‘Sleep Expert’ in your dental community, study club, or medical building. Claim your expertise, commit to continual learning, locate and nurture your collaborative team, share information, and you will truly be making a difference in community health.

“…the medical profession has to decide if it is going to keep its expert position or yield it to Apple…”

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

DentalSleepPractice.com

COVERstory

The Next Quest: Earning OAT Referrals from Physicians

“Without tradition, art is a flock of sheep without a shepherd. Without innovation it is a corpse.” – Sir Winston Churchill

by Mark T. Murphy, DDS, D.ABDSM, and Len Liptak, MBA

he Churchill War Rooms museum in London is a network of dank, subterranean bunkers where Sir Winston Churchill led Britain’s defense against the Nazis. Not only do the War Rooms pay homage to Churchill, the museum is a glorious tribute to crisis management. The fact that such a vast percentage of an otherwise modest area is allocated to collecting, analyzing, and funneling information to Churchill’s team is profound. Churchill understood that timely, accurate information, good news or bad, is essential for designing and optimizing war plans.

10 DSP | Summer 2020

COVERstory Though not on the same level as World War II, obstructive sleep apnea (OSA) is a public health calamity that requires expert crisis management. Everyone associated with Dental Sleep Medicine (DSM) can recite the key public health and economic statistics that characterize the urgent need for treating more OSA patients. Facts, figures, and policy abound; DSM continues to struggle with the myriad reasons many physicians remain cautious about oral appliance therapy (OAT). Policy statements on OSA treatment encourage patient preference.1 Multiple studies agree that 81% of patients prefer OAT.2 So why do sleep physicians only refer one out of ten patients for OAT?

Earning OAT Referrals

Finding resolution to this question is the next herculean quest for ProSomnus Sleep Technologies. Over the past few years ProSomnus has aggregated hundreds of data points from physicians boarded in sleep medicine. What have we learned? In the spirit of the Churchill War Rooms, ProSomnus is funneling this information to the DSM community. First and foremost, DSM must accept that physicians have legitimate reservations about traditional OAT. Acknowledgement is the first step in change management. “Firsthand clinical experience,” is cited as the primary source of reservations about OAT. Sleep physicians state that better scientific data and studies would be helpful, but their reservations about OAT are predominantly based upon what they experience with OAT patients during follow-up appointments. Across multiple surveys, 85% of the reservations cited by sleep physicians fall into one of four categories. These four categories are: efficacy, adherence, insurance coverage, and side effects. Let’s dig deeper.

Efficacy

Over 50% of respondents identify efficacy as their primary reservation about OAT. However, reliable disease alleviation, not single night in-lab AHI score, is the most common way respondents describe efficacy. In one survey of sleep physicians, just 9% thought OAT offered reliable disease alleviation. The underlying qualitative feedback on efficacious, reliable disease alleviation

“With ProSomnus Medical Devices, efficacy is not compromised with simplicity. Less protrusion, no moving parts and a company who listens, makes their devices a winner in the world of Dental Sleep Medicine.” – Kent Smith, DDS, D.ABDSM, D.ASBA

points to mechanical issues with traditional OAT devices. Physicians report that many traditional OAT devices have critical failures (activation screw slippage, devices not maintaining therapeutic position, device straps stretch, adjustable arms break, mechanisms malfunction, liners delaminate, etc.) by the follow-up visit with the physician. An abstract published at the 2014 AADSM indirectly shines some light on this issue, reporting that 21% of 309 patients treated with traditional OAT devices, ranging from 15% to 57% of patients depending on OAT device type, required some form of device intervention.3 This is not good enough. Imagine if a heart stent failed 21% of the time!

Adherence

Adherence is the second most significant barrier facing OAT. This may be surprising as most DSM practitioners assume that adherence is better with OAT than PAP therapy. There is a litany of research that demonstrates adherence with OAT,4 but many physicians have a different point of view. Another survey reports that 69% of sleep physicians cited patient discomfort as a key concern.5

Mark T. Murphy, DDS, D.ABDSM, is an American Board of Dental Sleep Medicine Diplomate and has practiced in the Rochester area for over 35 years. He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of Funktional Sleep, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and as a Regular Presenter at the Pankey Institute. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion. Len Liptak 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 Sleep physicians explain that patients report a level of discomfort that ultimately leads to the discontinuation of OAT. Once again, traditional OAT devices are a root cause issue. Devices are too big, too bulky, irritate the soft tissue, stain and smell, and may require over-protrusion to correct for design and manufacturing limitations.

Insurance Coverage

Insurance coverage is the third biggest reservation about OAT. There are two aspects to understanding this reservation: physician education and dental office billing capabilities. Most physicians are poorly educated about whether private insurance and Medicare cover OAT. 83% of respondents were not aware that OAT is covered by Medicare and most medical insurance plans. The second dimension to the insurance coverage reservation is that many dentists receiving referrals from physicians may not be enrolled in Medicare or may not know how to bill medical insurance. This could result in potentially avoidable out of pocket payment for the patient. If you are discussing OAT with a physician, educate them about insurance coverage. Inform them that your practice has experience billing insurance or utilizes a professional medical billing service. This will help reduce or eliminate this reservation.

Side Effects

Side effects are the last of the four key reservations. The most frequently reported examples of side effects are tooth movement, long term bite changes, and jaw pain. Although the side effects associated with traditional OAT are considered less severe than those associated with CPAP and should be disclosed in informed consent, they are nonetheless a main concern of sleep physicians.6 Further, recent studies have reported that modern OAT devices may be more capable of mitigating side effects.7

12 DSP | Summer 2020

A Path Forward

“My patients love ProSomnus appliances because of their low profile and ease of use. I love ProSomnus appliances due to the strong hygienic material, decrease in side effects compared to predicate appliances and overall how beautifully clean they remain at long term follow-up visits.” –Jason Ehtessabian, DDS, D.ABDSM, D.ASBA, D.ACSDD

Based upon this analysis, the dental sleep medicine community can earn more OAT referrals from sleep physicians by taking the following three actions: 1. Utilize Better Devices 2. Demonstrate Better Outcomes 3. Enhance Communication and Collaboration

Utilize Better Devices

The AADSM definition of an effective device, not PDAC lists, should guide OAT device selection.8 Today, modern, precision-engineered OAT devices exist that have better efficacy, are designed for patient comfort and side effect mitigation, and they offer more reliable performance post-delivery. Dentists can address physicians’ reservations by selecting devices not by price or habit, but rather by choosing devices that yield the best performance for your patient and from the perspective of the referring physician. When physicians feel confident patients will wear oral appliances causing fewer side effects and enjoy more comfort without hygiene or maintenance issues, they will embrace OAT more. When patients return to their sleep doctors with sore jaw joints or muscles, teeth movement, altered bite relationships or gunky looking appliances made from suck down, soft, or heat-sensitive porous materials we do ourselves no favors. We can and must do better today. Options exist today. Use them.

Demonstrate Better Outcomes

Oral appliance efficacy has been on a slow but steady upward slope for the past two decades. Devices like ProSomnus with precision bite transfer, lingual-less designs, and prescription posts with positive stops that ensure the therapeutic position, have pushed OAT even further toward desirable PAP results. When combined with higher compliance, the effectiveness and Mean Disease Alleviation have been demonstrated to be comparable or even superior to PAP therapy.9 As stated earlier, it is not just about the AHI score. Many physicians lament the poor quality of life experience that patients have when side effects appear and comfort wanes. Bands and straps need to be rigid enough to hold the therapeutic position or the device may fall short of the AADSM definition of

With ProSomnus

Dentists can earn OAT referrals from Physicians.

Recent surveys report sleep Physicians have legitimate concerns about traditional OAT. ProSomnus precision OAT devices are designed to address Physician barriers. “I visit Physicians almost every day and educate them about dental sleep. After I allay their fears about insurance, cost, compliance and efficacy, I often hear, ‘but they’re so big and bulky.’ Then I bring out the ProSomnus Precision Herbst…and now it’s, ‘Wow! I remember those things as being so big and bulky…this looks like anyone could wear it! If I send my wife over, will you give me a deal?” —Dr. Richard B. Drake, DDS, D.ABDSM “ProSomnus devices are one of my main ‘go to’ appliances because they act as a retainer, no shifting in teeth. Patients are not intimidated to initiate treatment due to their design quality. The patient’s established protrusive position remains intact and doesn’t gradually shift or stretch out as seen in other devices. Because of the precision engineering, patients are less likely to return for post insertion adjustments which frees up my schedule. My referring Physicians have given positive feedback stating how nice, discreet, stain-free, clean and hygienic the devices look and they are thrilled with the treatment outcomes.” —Dr. Nicole Chenet, DDS, D.ABDSM Join the growing number of dentists who are treating more patients with greater efficiency and effectiveness.

PRO3-248-A

Visit ProSomnus.com or call 844 537 5337 for a free starter kit.

844 537 5337 ProSomnus.com Leader in Precision OAT®

COVERstory

Figure 1: John A. Carollo, DMD, D.ABDSM, D.ASBA, predicate device after more than 3 years use

an effective appliance.10 Non-hygienic appliances can also lead to discontinued use. Most of us would be challenged to place an appliance like the one pictured in Figure 1 in our own mouth or a loved one’s mouth versus a clear, hygienic device as shown in Figure 2. We cannot accept poor outcomes because of ease of use or slight cost differentials. The outcomes Case Registry that I use from ProSomnus has been instrumental in demonstrating the effectiveness of my OAT with physicians.

“I love providing my patients with a better Oral Appliance option. Makes my job easier too, which is a win-win.” –Erika C. Mason, DDS, D.ABDSM, D.ACSDD

Enhance Communication and Collaboration

Communication is not limited to SOAP notes, faxing referring practitioners, and sending follow-up letters. It also means making sure that we let our medical counterparts know we are following the AASM/AADSM joint guidelines, using devices that meet the AADSM’s standards for an effective appliance, following standard procedures that mirror medicine, and that we are a qualified to practice dental sleep. Working with medicine and not counter to it, demonstrates our willingness to be part of the solution and NOT create unnecessary, avoidable friction. Whether you like it or not, physicians drive the sleep segment of health care. We will NOT increase the number of oral appliances prescribed by working around them, taking short cuts, or ignoring joint guidelines. Cooperation and collaboration can help medicine experience a paradigm shift in how they look at the OSA epidemic.

The Future

The future of DSM and Sleep Medicine

14 DSP | Summer 2020

Figure 2: John A. Carollo, DMD, D.ABDSM, D.ASBA, ProSomnus device after more than 3 years use

is bright. A recent third-party survey of over 100 sleep physicians reports that if we do these things physicians are likely to increase their OAT referrals by 30-40% over the next few years.11 Let’s create a better environment for our patients, practices, healthcare stakeholders, and payers. Let’s give physicians more reasons to trust Dental Sleep Medicine providers. There are enough headwinds gathering in the distance to shake up the space and create economic anxiety. Collaboration toward an efficacious, effective, comfortable solution with fewer side effects is the common goal. Following these steps will help redefine the gold standard for treating OSA to include Oral Appliance Therapy.

Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827. 2. Tan YK, L’Estrange PR, Luo YM, et al. Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: A randomized cross-over trial. Eur J Orthod. 2002;24(3):239-249. doi:10.1093/ejo/24.3.239. 3. Scott Craig’s abstract from the 2014 AADSM published in the JDSM. Note sure how to cite this. This is the poster title. POSTER #010Practice Management Implications of Leading Custom Mandibular Advancement Devices Scott Craig, James Hogg, Katherine Phillips, Richard A. Craig Midwest Dental Sleep Center, Chicago, IL, USA and this is the link to the JDSM page. https://aadsm.org/journal/abstracts_issue_12.php 4. Hu J, Liptak L. Evaluation of a new oral appliance with objective compliance recording capability: a feasibility study. Journal of Dental Sleep Medicine. 2018;5(2):47–50. 5. Medpanel Sleep Physician Survey, 2016. 6. Sheats RD, Schell TG, Blanton AO, Braga PM, Demko BG, Dort LC, Farquhar D, Katz SG, Masse JF, Rogers RR, Scherr SC, Schwartz DB, Spencer J. Management of side effects of oral appliance therapy for sleep-disordered breathing. Journal of Dental Sleep Medicine. 2017;4(4):111–125. 7. Vranjes N, Santucci G, Schulze K, Kuhns D, Khai A. Assessment of potential tooth movement and bite changes with a hardacrylic sleep appliance: A 2-year clinical study. J Dent Sleep Med. 2019;6(2). 8. Mogell K, Blumenstock N, Mason E, Rohatgi R, Shah S, Schwartz D. Definition of an Effective Oral Appliance for the Treatment of Obstructive Sleep Apnea and Snoring: An Update for 2019. J Dent Sleep Med. 2019;6(3). 9. Poster #016 Effectiveness and Efficiency of the ProSomnus® [IA] Sleep Device for the Treatment of Obstructive Sleep Apnea - The Effects Study, Stern J, Kuhns D. Blue Sleep, New York, 2Technology, ProSomnus Sleep Technologies, Pleasanton, United States, https://aadsm.org/journal/abstracts_issue_53.php 10. AADSM device definition, https://aadsm.org/docs/definitionoforalappliance.pdf 11. Fletcher Spaight International Sleep Physician Survey, 2020

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MEDICALinsight

Why Use an Anterior Only Stop with Oral Appliance Therapy? Less Adjustments and Less Forces by Barry Glassman, DMD, and Don Malizia, DDS

n terms of preventing major cardiovascular accidents, the use of oral appliance therapy (OAT) has been shown to be as effective as CPAP use in patients with severe obstructive sleep apnea (OSA). OAT effectiveness has been demonstrated as potentially effective for all levels of OSA severity – mild, moderate, and severe.1 Positive airway pressure, in its many forms, has long been heralded as the “gold standard” of care for OSA. The introduction of the smart card in CPAP raised the consciousness of the medical community to the compliance issue. Over time the term “effective AHI” was developed to consider the actual AHI during a full evening that combines the AHI that occurs when the CPAP is being used with the AHI that occurs when the CPAP has been removed during sleep.2 The documented, untoward effects of CPAP that may lead to poor compliance include discomfort from the mask, headaches from the straps, infections from poor cleaning, and bloating. The less obvious untoward effects of craniofacial changes that in some cases were quite severe are also now exposed.3 The introduction of oral appliances to the medical community at the end of the 20th century was not impressive. The monoblocs used by dentists were bulky and non-titratable, leading to inconsistent results with limited compliance and frequent side effects of joint pain and tooth movement. It wasn’t until 1995 when Schmidt-Nowara published

16 DSP | Summer 2020

his landmark paper suggesting that oral appliances could be successful in mild to moderate sleep apnea that OAT began to gain favor.4 In 1999 he published a second paper reporting oral appliance success in severe sleep apnea cases. Unfortunately, that paper never received the notice or fanfare that the first paper did.5 Consequently, to this day, many believe that oral appliances should only be used in mild to moderate OSA cases. Not only were these early appliances rather ineffective, but they frequently resulted in the untoward side effects of tooth movement and joint pain. These complications were exaggerated and used as additional reasons to discourage the use of oral appliances. While there are those who continue to suggest that a depth of knowledge of TMJ function and treatment of joint pain is required in order to treat sleep disturbed breathing with OAT, the truth is that many dentists without that depth of knowledge continue to treat many patients very successfully. In fact, it is noted that joint complications are uncommon and often overstated.6 An NTI is an appliance prescribed by thousands of dentists to control nocturnal parafunctional forces. The NTI has no posterior support and only a midpoint anterior contact. Despite the common contention that the lack of posterior support will lead to increased joint pain and other complications, Blumenfeld, et al published results of an independent provider-based survey involving the use of an anterior midpoint stop design

MEDICALinsight in 5,807 patients. The results demonstrated a high degree of success with the appliance for treatment of orofacial pain and favorable patient outcomes. Complications were very low in this large cross-sectional sample, and the appliance actually resolved joint pain as opposed to causing pain in many instances.7

A Brief History of Anterior Midpoint Stop Appliances

Costen, in 1934, postulated that posterior contact was necessary for “joint support.” Costen was an otolaryngologist who reported 12 cases of decreased joint pain when vertical dimension was increased.8 The need for posterior contact remained a prevailing concept, and several temporomandibular joint gurus based their treatment protocols on occlusion and balanced posterior contacts. In 1979 Hylander, an anthropologist and anatomist, measured joint load on a dry skull while applying force at various points along the mandible. Nitzan cites his proposal that the more posterior the contact, the lower the force to the joint.9 However, it has since been demonstrated that while this may be the case on a dry skull, it is not the case in vivo. Miralles measured EMGs which revealed that with anterior-only contact, maximum voluntary clenching was reduced by 75% in the anterior temporalis and 55% in the masseter.10 In 2003, Hattori technically calculated joint load with a finite element analysis, demonstrating with shorter arches that moving the occlusal contact anteriorly, actually lowered joint force.11 Baad-Hansen, in 2007, demonstrated that there were reduced EMG forces during parafunction with anterior midpoint stop appliances, and in 2008, Stapelmann supported this same concept.12,13

The Anterior Midpoint Stop Advantage in OAT

Holding the mandible in a protrusive posture supported by an appliance does not add strain to the joint structure. The tendency to cause strain or sprain in a joint that leads to effusion and increased pain is most likely to occur during parafunction. Miralles’s studies demonstrated that there is a significant reduction of EMG activity in the elevator muscles during the parafunctional event with anterior midpoint stop appliances9 (see Figure 1).

Figure 1: EMG readings depicting maximum voluntary clenching intensity with a full-coverage splint in place (top) and significantly decreased intensity with an anterior midpoint stop in place (bottom)

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

DentalSleepPractice.com

MEDICALinsight Another real advantage of having only anterior contact is that inserting the appliance becomes less dependent on well-balanced posterior occlusion. The lack of posterior contact becomes even more significant as protrusive titration takes place and there is no concern about altered posterior contact.

...with anterior-only contact, maximum voluntary clenching was reduced

75%

The Myth of Retrodiscal Compression Caused by Anterior Midpoint Stop Appliances The prevailing misconception contends that parafunction in the absence of posterior contact will lead to posterior superior posturing of the condyle. The theory suggests this consequence will result in compressions of the highly vascularized and innervated retrodiscal tissues. Careful evaluation of the force vectors created by the combination of the masseter and anterior temporalis reveals that the mandible is not guided posteriorly by their action, but actually anteriorly and superiorly. The mandibular motion is very different in vivo than typically presented in two dimensional diagrams (see Figure 2).

Conclusion Despite the preponderance of literature indicating otherwise, TMJ damage or joint pain remains a major contraindication for oral appliance therapy or a contributing factor in discontinuing efficacious oral appliance use. This misconception can preclude viable candidates from receiving OAT or lead well-intentioned but misinformed clinicians to discontinue use, therefore jeopardizing the quality of the patient’s general health. It been noted that temporomandibular joint pain is not common with the use of oral appliance therapy for sleep disturbed breathing. Additionally, the likelihood of developing joint pain can potentially be decreased or eliminated when it occurs by moving the dental contact further anterior or utilizing anterior midpoint stop appliances.

10.

11.

12.

13.

Figure 2: A-B: Resting on anterior midpoint stop. C-D: Maximum clench on anterior midpoint stop.

18 DSP | Summer 2020

Anandam, A., et al., Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: An observational study. Respirology, 2013. 18(8): p. 1184-1190. Boyd, S., et al., Effective Apnea-Hypopnea Index (“ Effective AHI”): A New Measure of Effectiveness for Positive Airway Pressure Therapy. Sleep, 2016. 39(11): p. 1961-1972. Tsuda, H., et al., Craniofacial Changes After 2 Years of Nasal Continuous Positive Airway Pressure Use in Patients With Obstructive Sleep Apnea. Chest, 2010. 138(4): p. 870-874. Schmidt-Nowara, W., et al., Oral appliances for the treatment of snoring and obstructive sleep apnea: a review. Sleep, 1995. 18(6): p. 501-10. Schmidt-Nowara, W., Recent Developments in Oral Appliance Therapy of Sleep Disordered Breathing. Sleep Breath, 1999. 3(3): p. 103-106. Doff, M., et al., Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on dental side effects. Clin Oral Investig, 2012. online: p. 1-8. Blumenfeld, A., et al., Patterns of Use for an Enhanced Nociceptive Trigeminal Inhibitory Splint. Inside Dentistry, 2011. 7(11). Costen, J.B., A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. 1934. Ann Otol Rhinol Laryngol, 1934. 106(10 Pt 1): p. 80519. Nitzan, D., Intraarticular pressure in the functioning human temporomandibular joint and its alteration by uniform elevation of the occlusal plane. J Oral Maxillofac Surg., 1994. 52(7): p. 671-9. Miralles, R., et al., Influence of protrusive functions on electromyographic activity of elevator muscles. Cranio, 1987. 5(4): p. 324-32 contd. Hattori, Y., et al., Occlusal and TMJ loads in subjects with experimentally shortened dental arches. J Dent Res, 2003. 82(7): p. 532-6. Baad-Hansen, L., et al., Effect of a nociceptive trigeminal inhibitory splint on electromyographic activity in jaw closing muscles during sleep. J Oral Rehabil, 2007. 34(2): p. 105-11. Stapelmann, H. and J.C. Turp, The NTI-tss device for the therapy of bruxism, temporomandibular disorders, and headache: where do we stand? A qualitative systematic review of the literature. BMC Oral Health, 2008. 8(1): p. 22.

THE VERSATILE APPLIANCE THAT WORKS FOR THE MAJORITY OF PATIENTS

THE MEDLEY SLEEP APPLIANCE

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Three Different Design Applications

THE MEDLEY ROD SLEEVE SLEEP APPLIANCE utilizes a “pushing” force. The Telescopic Herbst Rod Sleeve mechanism offers superior strength and firmer jaw positioning. PDAC-approved.

THE MEDLEY RIGID NYLON LINKS SLEEP APPLIANCE, ideal for the majority of qualified patients, utilizes a mandibular “pulling” force. The nylon link material provides a more rigid, firmer advancement feel and won’t deform.

THE MEDLEY ELASTOMERIC SLEEP APPLIANCE utilizes a mandibular “pulling” force. The subtle stretching characteristic of the elastomeric (EMA) straps allows maximum comfort during advancement. Ideal for patients with tender joints or loose teeth.

* Herbst is a registered trademark of Dentaurum, Inc.

“The Medley sleep appliance gives me the ability to address specific patient needs and circumstances without delay or multiple appliances.” —Robert Rogers, DMD, DABDSM, Inventor of the Medley

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Learn more at MedleySleepAppliance.com or call 800.828.7626

PEDIATRICS

The

Future Face

of Sleep

by Sharon Moore

n this multi-part series, author, speech pathologist, and myofunctional practitioner Sharon Moore shares the ramifications of poor sleep on mental, emotional, and physical wellbeing, along with screening techniques to help dental teams identify the common red flags of disrupted sleep. In subsequent issues, she will introduce myofunctional therapy as a method to optimize growth, development and maintenance of healthy facial and upper airway structures to counteract sleep disorders like sleep disordered breathing and upper airway resistance syndrome. In Part 1, Sharon outlines the importance of sleep for adults and children, as well as highlighting the link between sleep problems and upper airway issues. She also shares how dentists are perfectly positioned to screen problems early and collaborate with other health professionals on intervention. 20 DSP | Summer 2020

In America, 70% of adults report experiencing insufficient sleep at least one night a month, and 11% report insufficient sleep every night.1 Meanwhile, a British study showed 77% of British adults do not wake refreshed,2,3 and an Australian study reported inadequate sleep, of either duration or quality, affecting 33-45% of Australian adults.4 In children, up to 40% of 4 -10 year-olds have sleep problems – that’s a lot of children!5 Furthermore, since 80% of kids’ sleep problems are missed, dismissed or misdiagnosed, there are gaps that must be bridged in screening, education and clinical solutions for sleep problems. This is partly attributable to lack of education across community and professional groups, but also because sleep problems can masquerade as behavior and learning problems.6 Regardless, it’s a very big problem.

PEDIATRICS The Consequences of Poor Sleep in Adults

There is not one body system nor one domain of health, social, or workplace functioning that is not impacted by poor sleep, yet many adults remain unaware of the importance of sleep. In fact, the cost to governments for untreated sleep problems is in the billions.7 Furthermore, we know that sleeping only 6 hours per night can decrease immunity by 70%, notwithstanding the other possible consequences of poor sleep: chronic inflammation, tumor growth, stress and impacts on endothelial, endocrinological, metabolic, cardiovascular, and integumentary systems.8

The Consequences of Poor Sleep in Children

The same goes for children. There is not one system nor domain of childhood development not affected by poor sleep; physical, mental, emotional or social no matter the cause or the severity.9,10,11 The impacts may have ripple effects throughout childhood, adolescence, and beyond when untreated; including the very education and safety of our children by way of the neuro-behavioural and cognitive deficits associated with poor sleep.12

e.g. The landmark study of 11,000 children Professor Karen Bonuck et al, in 2012 showed that behavioural difficulties at age seven (age eight for children in special education) were linked to having had sleep problems prior to five years of age.13 Furthermore, sleep disordered breathing and short sleep duration were both linked to children’s increased odds of becoming overweight.14 Meanwhile, a study at Duke University in 2015 showed that children with attention problems in early childhood were 40% less likely to graduate from high school.15

So, What is Good Sleep?

It’s quite simple: good sleep = correct quantity + good quality. The results of good sleep are waking refreshed and managing natural energy peaks and troughs throughout the day.16 Bad sleep, in contrast, is any version of insufficient quantity and/or poor-quality sleep, which can impact our physical, mental, and emotional health. Bad sleep can also have a deleterious effect on performance, safety, and productivity.17

Where Does Upper Airway Fit in this Picture?

Poor sleep is a global epidemic – ‘perhaps one of the greatest challenges of the 21st Century.’18 Insomnia is the biggest problem and sleep disordered breathing (SDB) ranks second. SDB hinges directly on upper airway health and function, with conditions including obstructive sleep apnea (OSA), snoring, upper airway resistance syndrome,

Sharon Moore is an author, speech pathologist and myofunctional practitioner with 4 decades of clinical experience across a range of communication and upper airway disorders. She is on the transdisciplinary team for the Canberra Sleep Clinic and has a special interest in early identification of craniofacial growth anomalies in children, concomitant orofacial dysfunctions and airway obstruction in sleep disorders.

DentalSleepPractice.com

PEDIATRICS

respiratory effort related arousals and mouth breathing. Currently, the apnea-hypopnea index (AHI) that measures OSA does not capture the full spectrum of narrowing and collapse of the upper airway that occurs in SDB, leading to varying degrees of poor-quality sleep. The outcome is disruption of breathing and sleep architecture. With 40% of cranio-facial growth being complete by age 4 and 90% complete by age 11-12, there is a critical window of opportunity to develop the healthiest possible airway.

What Does that Mean in a Dental Practice?

The ADA states â&#x20AC;&#x153;All dentists should screen for SDB/OSA.â&#x20AC;? 19,20 Dental teams are face-toface with patients every single day, on the frontline for identifying sleep and upper airway issues. Here are the top three things dental teams can do: 1. Screening: Use sleep questionnaires and screen for upper airway issues impacting sleep, including anatomy, tissue, and neuromuscular function. 2. Education: Promote sleep and healthy upper airway along with dental hygiene to your whole team as well as your patients. 3. Clinical solutions: If you have adequate knowledge of dental sleep med-

22 DSP | Summer 2020

THE FLAT PLANE SPLINT HAS BEEN USED SINCE 1901. IT’S TIME TO ADVANCE.

INTRODUCING THE POD® FEATURING UNILATERAL BITEBLOCK TECHNOLOGY® The POD® is a custom fit, laboratory fabricated intraoral mandibular splint designed to aid in treating bruxism and TMJ Dysfunction. Worn during sleep, the device serves to protect the teeth and restorations from the destructive forces of bruxism and will help to alleviate TMJ/TMD, headaches, and facial muscle pain. The unique design increases anterior tongue space while limiting the amount of occlusal contact points with the maxillary arch. Limiting occlusal contacts allows for a reduction of trigeminally innervated muscular activity and can reduce muscle tension and help alleviate associated TMJ pain symptoms and headaches. FDA 510(k) CLEARED

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PEDIATRICS icine, be part of the multidisciplinary team treating SDB/OSA patients.

It Takes a Team

40% Up to

of 4-10 year-olds have sleep problems.

Approximately 30% of sleep problems can be solved by developing healthy sleep habits.21 The rest require expert help from medical, dental, and allied health professionals. Dental teams truly are on the frontline to help patients and their families discover the life-changing magic of great sleep.22 However, to provide complete solutions for patients’ airway and breathing issues, it’s essential to work alongside other medical and allied health professionals whose expertise is required for developing and maintaining healthy breathing during sleep. These include sleep specialists, ENTs, oro-maxillofacial surgeons, allergists, and myofunctional therapists, among others.

Sleep and Health in the 21st Century

While poor sleep has far-reaching negative consequences, the converse is true for good sleep. Good sleep leads to optimal emotional, physical and mental development in children, optimal work and academic

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

20. 21. 22.

performance, road and occupational safety, robust mental and emotional health for adolescents and adults. It is mission critical for everyone to get the sleep they need every night to be healthy and happy. In order to achieve this, over the following three installments I will expound upon how to screen for disordered sleep and recognize the common red flags that represent when sleep is less than optimal. I will also introduce myofunctional therapy as a tool to address upper airway issues, including giving an overview of key oral functions that assist in the development of the airway, and sharing some of my go-to exercises for patients presenting with SDB and other issues of the upper airway. Finally, I will take an in-depth look at Upper Airway Resistance Syndrome, including its impact on sleep and development, the challenges of identifying the disorder, and how dental teams can contribute to screening for and treating this disorder. By engaging with this series, you can help create the face(s) of our future and solve one of the greatest health challenges of the 21st Century.

Centers for Disease Control and Prevention. Perceived Insufficient Rest or Sleep Among Adults—United States, 2008. Morbidity and Mortality Weekly Report 58:1179 Sealy UK & Loughborough University Clinical Sleep Research Unit. (2016) The world’s largest-ever online ‘sleep census’ reveals a sleep-deprived planet. [Online] Available from: http:// www.lboro.ac.uk/media-centre/press-releases/2016/november/the-worlds-largest-ever-online-sleep-census-reveals-a-sleep-deprived-planet.html Institute of Medicine, ‘Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem’, (Washington, DC: National Academic Press, 2006), https://doi.org/10.17226/11617. Adams, Robert J., Sarah L. Appleton, Anne W. Taylor, et al. “Sleep Health of Australian Adults in 2016: Results of the 2016 Sleep Health Foundation National Survey.” Sleep Health3, no. 1 (2017): 35-42. doi:10.1016/j.sleh.2016.11.005. Owens & Chervin, ‘Behavioral Sleep Problems in Children’, https://www.uptodate.com/contents/behavioral-sleep-problems-in-children David L. Rabiner, Jennifer Godwin and Kenneth A. Dodge, ‘Predicting Academic Achievement and Attainment: The Contribution of Early Academic Skills, Attention Difficulties, and Social Competence’, School Psychology Review 45, no. 2 (2016): 250–67, https://doi.org/10.17105/spr45-2.250-267. ‘The Price of Fatigue’, Harvard Medical School, PDF document, December 2010, https://sleep.med.harvard.edu/file_download/100. Luciana Besedovsky,1,2 Tanja Lange,1,2 and Jan Born1,2, Sleep and immune function, Pflugers Arch. 2012 Jan; 463(1): 121–137. Published online 2011 Nov 10. doi: 10.1007/ s00424-011-1044-0 Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing 2019). Alison L. Miller, Julie C. Lumeng and Monique K. Lebourgeois, ‘Sleep Patterns and Obesity in Childhood’, Current Opinion in Endocrinology & Diabetes and Obesity 22, no. 1 (2015), https://doi.org/10.1097/med.0000000000000125. Ann C. Halbower, Mahaveer Degaonkar, Peter B. Barker, Christopher J. Earley, Carole L. Marcus, Philip L. Smith, M. Cristine Prahme and E. Mark Mahone, ‘Childhood Obstructive Sleep Apnea Associates with Neuropsychological Deficits and Neuronal Brain Injury’, PLoS Medicine 3, no. 8 (2006), https://doi.org/10.1371/journal.pmed.0030301. M. Obrien, ‘Neurobehavioral Implications of Habitual Snoring in Children’, Pediatrics 114, no. 1 (2004): 44-49, https://doi.org/10.1542/peds.114.1.44. Karen Bonuck, Ronald D. Chervin and Laura D. Howe, ‘Sleep-Disordered Breathing, Sleep Duration, and Childhood Overweight: A Longitudinal Cohort Study’, The Journal of Pediatrics 166, no. 3 (2015), https://doi.org/10.1016/j.jpeds.2014.11.001. Karen Bonuck, Ronald D. Chervin and Laura D. Howe, ‘Sleep-Disordered Breathing, Sleep Duration, and Childhood Overweight: A Longitudinal Cohort Study’, The Journal of Pediatrics 166, no. 3 (2015), https://doi.org/10.1016/j.jpeds.2014.11.001. David L. Rabiner, Jennifer Godwin and Kenneth A. Dodge, ‘Predicting Academic Achievement and Attainment: The Contribution of Early Academic Skills, Attention Difficulties, and Social Competence Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing, November 2019). Sharon Moore, Sleep-Wrecked Kids: Helping Parents raise happy healthy kids one sleep at a time. (New York: Morgan James publishing 2019). Matthew Walker, Why We Sleep. Penguin Random House, October 2017 Silvia Gianoni-Capenakas, DDS, MSc, PhD1, Andre Chiconelli Gomes, DDS2, Pedro Mayoral, DDS, MSc, PhD3, Manuel Miguez, DDS, MSc, PhD4,5, Benjamin Pliska, DDS, MSc, PhD6, Manuel Lagravere, DDS, MSc, PhD7, Sleep-Disordered Breathing: The Dentists’ Role – A Systematic Review, Journal of Dental Sleep Medicine, Review Article 1, Issue 7.1, http://dx.doi. org/10.15331/jdsm.7108 American Association or Orthodontics Whitepaper, (2019) https://www.semanticscholar.org/paper/American-Association-of-Orthodontists-White-Paper-%3A/cbddda450eb7be89dbf 192e87445f3c443764856 Sarah Blunden, ‘Behavioural Sleep Disorders across the Developmental Age Span: An Overview of Causes, Consequences and Treatment Modalities’, Psychology, no. 3 (2012): 249–56, https://doi.org/10.4236/psych.2012.33035. Sharon Moore, ‘Sleep Disorders are in your face’, in The 2nd AAMS Congress (Chicago, 2017).

24 DSP | Summer 2020

PRODUCTspotlight

Teledentistry Brings HealthyStart Home by Brooke Stevens

ediatric Sleep Disordered Breathing (SDB) is a silent epidemic that affects the overall health of children. In this current climate that sees families and our nation contending with the COVID-19 pandemic, it is imperative to focus on the practice of optimal health and the prevention of disease. Parents are focusing on sanitization and practicing social distancing, but are parents looking at the current health issues of their children that may be affecting their ability to attain optimal health? SDB is a condition that can impact the immune, endocrinal, hormonal, and neurological systems. Research shows that 9 out of 10 children exhibit one or more outward symptoms of SDB (Stevens et al, 2016). Providing education for parents and medical professionals is crucial.

Treated with the HealthyStart system

Brooke Stevens is in research and development for HealthyStart.

26 DSP | Summer 2020

Our goal is to educate and train dental professionals to understand the critical role they play in identifying and treating this epidemic in pediatric patients. For over 53 years, HealthyStart/Ortho-Tain has studied and treated more than 4,000,000 patients, which has contributed in shaping and executing a system of expertise that is able to effectively treat many of the underlying root causes of this condition. The initial tools that HealthyStart provides include a comprehensive sleep and speech questionnaire that identifies mouth breathing, snoring, ADHD, bed-wetting and many others, as well as the degree of severity of these conditions. A further evaluation of the underlying root causes can determine a child’s oral deficiencies, including lack of growth and development, improper oral habits, and treatment of the orthodontic conditions. The HealthyStart’s unique system is comprised of a series of specially designed appliances that efficiently and effectively address these deficiencies. The HealthyStart system is easy to implement in any office and requires far less chair time than traditional orthodontics. It has become increasingly necessary for doctors to be able to utilize teledentistry to ensure “non-emergent” patient care continues regardless of any national emergency. The HealthyStart system can easily be integrated with a combination of in-office visits, as well as via teledentistry. This option allows the doctor to fill valuable chair time for other patients and improve access and convenience of care for patients. Teledentistry can also give patients improved access to education and information about their oral condition. The HealthyStart offers a digital education series that educates doctors and their offices on the HealthyStart system, implementation of both in office and teledentistry protocols, hands-on treatment and interactive study groups, all to provide top of the line care to your patients. Visit www.thehealthystart.com to sign up now and educate your patients and your community with advanced technology in treating every child’s overall health.

EXPERT view

In Your Own Words

t is vitally important that dentists develop relationships with their physician colleagues so they can become part of the multidisciplinary team needed to adequately manage sleep disordered breathing patients. In each issue of Dental Sleep Practice, we ask prolific Dental Sleep practitioners from across the country a set of three questions. In this issue, we asked the following questions about best practices for developing and maintaining relationships with referring physicians. These are the responses “In Your Own Words.” 1. How did you develop a relationship with your most prolific referring physician? 2. What do you do to maintain that relationship? 3. What words of wisdom would you share with someone trying to do the same?

Mayoor Patel, DDS, MS

1. I began by sending them patients for diagnosis and management. After several of my patients had gone through their practice, I approached the physician to have a face-to-face discussion. While meeting with the physician, we were able to discuss those mutual patients that we had and the care they were receiving. From that point, I introduced myself, and the services I offer. This led to a mutual, bi-directional working relationship that allows us to successfully collaborate with each other to care for our patients. 2. This is a very important part of the collaboration process. We make sure that when the referral comes in, we contact the patient in a timely manner. We want to ensure that the patient can be seen for a consultation as quickly as possible to improve outcomes. Once a consultation and discussion for treatment are provided, we fax a letter to the referring physician to keep them in the loop with their patient’s care. We continue to provide this type of knowledge and care to all referral patients to maintain an ongoing, successful, and professional relationship between offices. This helps us ensure the best possible outcomes for our patients.

28 DSP | Summer 2020

3. Be patient with the process. You don’t develop these relationships overnight or at the drop of a hat. It takes time to mature a working relationship, as it does in most areas of our lives. Remember to also keep the physician in the loop as to what care the patient is receiving and whether their patient does or does not consider the treatment plan you suggest. Additionally, with every follow up visit you do with their patient make sure to send a follow-up note faxed to their office. And lastly, be available to answer any of the questions that they might have along the way. Together you can create a mutually beneficial working relationship.

Steve Carstensen, DDS

1. I found out what problems the doctor was having and set out to solve them. I listened to their concerns and addressed them. I didn’t just do what I was told, but I was clear who is in charge. 2. I make sure they hear from me about every patient – and that includes the ones I discover have abandoned their oral appliance and need other options 3. Dr. Pankey taught us to ‘Know our Patient’ – you can carry that on to knowing who you want to do business with, how they approach their work, and see how you can fit in and provide service to them and their patients that no other dentist is making the effort to do. If you can meet the ARNP and connect your admin with theirs, all’s the better. This effort is way more than sending a letter or dropping off cards at the front desk.

Kent Smith, DDS

1. I wish I could say I had one most prolific referring physician, but many of my sources have about the same level of referral frequency. Great patient feedback to the physician after being in our office has worked wonders. This is accomplished by being in network, minimizing out of pocket expense for the patient, and providing various appliances for specific needs.

EXPERT view 2. I communicate frequently with faxes and letters. They receive a fax when the patient they have referred has scheduled, then they receive letters after they have begun treatment and again when the patient is ready to return for a follow up study. 3. Just be patient. You can’t win an MD over in a day. Then treat patients the way you would want to be treated. Your reviews will show this, so one goal could be to get as many reviews as possible. You can learn much from these online patient reviews.

Justin Elikofer, DDS

1. Lunch and Learns and follow through; ask questions. You are not there to present on dental sleep therapy or oral appliance therapy. Focus on the interests of the office. No one gets a second date talking about themselves the whole time. 2. Send a ton of letters. It makes you appear more confident, knowledgeable, and communicative. Don’t forget this is a life-threatening disease process and the physician actually cares what has been going on over the past 8 weeks of appliance titration. Keep them informed. 3. Why do you refer to your endodontist or OMFS? It’s not because they called and asked or had a lunch and learn. It’s because they make your life easier, they do good work, and make you look better. Focus on discovering what that means to each physician and exceed their expectations. This takes work and emotional intelligence, but it isn’t rocket science. You can do this.

Damian Blum, DMD

1. Several years ago, I received a patient referral from a doctor who was part of a pulmonology group at a local hospital. The patient she referred had an AHI of 145.6 and other associated issues. I asked why she referred this patient to me. She said that she looked me up online and read my reviews. After examining the patient, evaluating her history and measuring the desired therapeutic position, the appliance was made and delivered. Her subjective symptoms of snoring, head-

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aches, nocturnal urination, and excessive daytime sleepiness were significantly diminished, and some were eradicated. Her follow up in-lab PSG with her oral appliance and no titration yielded an AHI of 19 with significant oximetry improvement also. After that case I began to receive multiple referrals from various MDs in that group. We discussed cases together in writing and in direct conversations. I also spent some late evenings and nights with their technicians at their sleep labs and helped with oral appliance titrations. Eventually I was assigned to spend one day with a particular sleep doc who was also a neurologist boarded in sleep. This last doctor became my most frequent referrer. 2. To help maintain the relationship, I also refer to her and her team of doctors who are really good at what they do. We also discuss new technology, new procedures, new research and articles related to our professional relationship as well as other associated research. However, we do not discuss finances associated with our relationships. 3. My advice is to do what I did. When I asked physicians about what made them refer to me and others, a few things stood out. Initially they will refer based on expertise and ability to get desirable results. Whether they continue to refer comes down to bedside manner, quality of service, patient satisfaction, and geographic proximity.

Erin Elliott, DDS

1. Spending time and befriending the head sleep tech. Then the sleep doc via email and golf. He was always so busy. We worked together for two years before we actually met in person and then we hit the golf course. 2. Ask questions, provide new research and products from the dental side, collaborate on difficult patients. 3. Demonstrate a genuine motivation to help patients, bill medical insurance including Medicare, and have patients go back and report success and gratitude for referring them to us.

DENTAL

SLEEP MEDICINE Mini-Residency 2020-2021

Boston, Massachusetts, USA Module I: October 8 -10, 2020 Module II: January 14 -16, 2021 Module III: April 8 -10, 2021

Tufts University School of Dental Medicineâ&#x20AC;&#x2122;s Dental Sleep Medicine Mini-Residency has been designated as an Accredited AADSM Mastery Program Provider.* Attendees of accredited Mastery Program Provider programs are eligible to earn the AADSM Qualified Dentist designation and apply for the ABDSM certification exam through the Mastery Track.

Registration open! Space is limited.

dental.tufts.edu/CE Check our website for online offering updates

Further questions, please contact dentalce@tufts.edu or 617-636-6629 * This program meets the accreditation standards to be an AADSM Mastery Program Provider; however, the AADSM does not endorse, recommend or give preference to this program; faculty; or any product, device, or appliance discussed within this program. Any opinion expressed or communication regarding any product, device or appliance is solely the opinion of the individual(s) expressing or communicating that opinion, and not that of the AADSM.

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Pediatric Dental Sleep Medicine Mini-Residency Program Module I: Multi-Session Online November 7, 2020 January 9, 2021 March 12, 2021 Module II: On Campus April 30 - May 2, 2021

Temporomandibular Disorder (TMD) Mini-Residency Program Module I: Online November 20 - 22, 2020 Module II: On Campus April 23 - 25, 2021

PRACTICEmanagement

Medical Billing for Telemedicine for DSM by Rose Nierman, Founder & CEO, Nierman Practice Management

here’s a new buzzword in town, and that word is Telemedicine. Telemedicine encounters for Dental Sleep Medicine (DSM) are increasing, and rightly so! Research reports that telehealth interventions produce positive outcomes that are at the same level as face-to-face encounters. The most consistent benefit is when telemedicine is used for communication, counseling, and monitoring of chronic conditions. In addition to DSM, telemedicine is commonly utilized for dental emergencies. Remote consults significantly reduce emergency room (ER) visits for patients with dental issues and frees up resources for other ER patients. During the remote session, medications, counseling, and instructions can be provided along with any needed recommendations for follow up care.

As always, documentation is crucial to support billing of How Do I Code Telemedicine to consults, x-rays, Medical? Coding varies by insurance carriers, so and custom-made check with insurance plans to determine the oral appliances coding guidelines. Many commercial carriers accept the same evaluation and managefor Obstructive ment (E&M) codes that you would use for a Sleep Apnea. face-to-face encounter, such as CPT 99202 for a new patient level 2 E&M visit. The dental practice can indicate that the encounter was a telemedicine visit by appending a CPT modifier (modifier 95 or GT) and/or using a place of service code that specifies telemedicine (place of service code 02). Other medical insurers utilize the new 2020 CPT telemedicine codes:

Rose Nierman’s online medical billing course series, Nierman CE+ and her live cross-coding continuing education courses have helped thousands of dental practices learn and apply medical billing. Her company, Nierman Practice Management, created DentalWriter™ software to generate medical claims and narrative reports, and Nierman Medical Billing Service to handle the insurance communication for clients. Rose and her company have been dedicated to helping dentists and their teams for 32 years. For more information: contactus@dentalwriter.com or 800-879-6468.

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99422

Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5–10 minutes 99422 11–20 minutes 99423 21 or more minutes Insurers have loosened guidelines for telemedicine reimbursement as a result of the COVID-19 pandemic. For example, Medicare’s adjusted telemedicine guidelines in response to the pandemic lifted restrictions that were previously in place that limited coverage for telemedicine services to situations such as beneficiaries in rural areas and/or with ambulatory limitations. Commercial carriers are now strongly recommending that patients utilize telemedicine for many situations. As always, documentation is crucial to support billing of consults, x-rays, and custom-made oral appliances for Obstructive Sleep Apnea. Nierman Practice Management’s (NPM) DentalWriter™ questionnaire and exam forms generate a SOAP narrative report and the questionnaire can be completed online by the patient. Another SOAP report can be easily created for the oral appliance visit. Note that some insurers are now requesting a SOAP report for both encounters. Additionally, NPM can help guide practices on solutions and can recommend a telemedicine platform with sleep physicians who are experienced in working with dentists for oral appliance therapy. Please feel free to contact NPM for documentation, coding, and telemedicine solutions. We’re always happy to help your practice with DSM and medical billing implementation!

CHOOSINGappliances

COVID-19:

A Paradigm Shift for the Treatment for Sleep Related Breathing Disorders

by Keith Thornton, DDS

he COVID-19 pandemic has created a paradigm shift in the medical acceptance and patient expectation of telemedicine as a treatment pathway. The treatment of Sleep Related Breathing Disorders (SRBD) is no exception. There are three aspects of the treatment of SRBD to be taken into consideration: 1. Options and opportunities for telemedicine 2. Use of an immediate appliance for diagnosis, treatment, and long-term management 3. Future potential for dentists and physicians

…using TAP, patients with an average pre-treatment of 30 (severe) while Options and Opportunities As we turn our attention toward telemedpost-treatment it icine and SRBD, workflows must be develwas 8.3, virtually oped for both diagnosed and non-diagnosed patients, and immediate appliances can play the same as CPAP. an integral role. These new workflows pro-

vide opportunities for dentists, sleep physicians, and other practitioners to address and support patients’ needs right now. With guidance, patients are able to fit some of these appliances remotely. Not all immediate appliances are created equally, and it’s recommended that clinicians provide patients with appliances that are proven most effective compared to other non-custom appliances that are available.

Why myTAP?

The myTAP is the culmination of more than 25 years of incremental improvements and developments. It is unique in that it not

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only positions the mandible protrusively but also vertically and encourages nasal breathing utilizing the proprietary mouth shield. All oral devices have two characteristics in common: They all have a tray system for attaching to the teeth, and all have some kind of mechanism for positioning the mandible The myTAP is not made on casts. Instead, it is directly fit to a patient’s teeth without any interim steps that can lead to errors with fit and retention. The Flexible Precision™ unique property of the material allows the trays to fit the teeth precisely with the proper resiliency necessary to maintain appropriate retention with a passive fit. The trays themselves are thinner and take up less space in the oral cavity than any other non-custom device. Additionally, it can be refit an unlimited amount of times to create the correct amount of retention for that patient which is critical for a patient fitting themselves at home. The myTAP is a modified version of the original TAP. The TAP has over 40 peer reviewed, independent studies and is both the most efficacious and effective device on the market. In the 2015 AASM guidelines, the TAP was the only appliance that was successful in treating all levels of apnea to below 10 AHI.1 • In three studies by Hoekema, the average AHI before treatment was 40.3 while the average afterward was 6 – an 85% reduction. All six studies on the TAP met the AASM oral appliance success criteria (greater than 50% reduction, less than 10 AHI.) • In six studies, dorsal-style devices failed to reduce the AHI to below 10

IMMEDIATE TREATMENT PROVEN TECHNOLOGY

TREAT PATIENTS IMMEDIATELY WITH THE TAP SLEEP CARE SYSTEM From predictor appliance to custom solutions, the TAP System offers a range of advanced devices for comfortable and effective treatment. For more information on treating patients remotely with telemedicine and the myTAP interim oral appliance, email contactami@amisleep.com or call 866.264.7667

866.264.7667 contactami@amisleep.com

CHOOSINGappliances come improvements utilizing the 6mm for women (9mm for obese) and 9mm for men (12mm for obese). The mouth shield encourages physiologic (nasal) breathing as most healthy sleepers tend to nasal breathe during sleep. The Guilleminault study found that airway resistance, and the risk for OSA, is significantly lower when breathing nasally. Physiologic breathing, which maintains proper CO2 levels, controls respiratory drive, reduces sympathetic tone, humidifies, heats, and filters the air. It also provides an uptake in nitric oxide. myTap appliance

even though the average starting AHI was only moderate. • Herbst had three studies with only mild to moderate patients. One failed to achieve the 10 AHI criteria while the other two only reduced the AHI by 60%. • An Army study (N=497) using TAP, had patients with an average pre-treatment of 30 (severe) while post-treatment it was 8.3, virtually the same as CPAP. The newest feature improvements to the myTAP are vertical adjustments and a mouth shield to encourage nasal breathing. The myTAP has 3 vertical shims available to give a 6mm, 9mm, and 12mm vertical opening. In the studies by both Hoekema and the Army, the “size of the box” of the oral cavity correlated to successful outcomes. Further studies have shown that the size of the tongue is dependent on weight, and it affects the severity of OSA. To compensate for tongue size, a larger vertical opening is necessary. Preliminary data from ACTA (Amsterdam) shows significant out-

Future Implications

The future is already here – NOW! The opportunity to develop a standard of care for evaluation and treatment of SRBD via telemedicine exists today. The value for the physician and dentist is the added perceived, and real, value in the “chronic disease management” of these patients through yearly follow-up to assess efficacy and coach the patient. In-office visits can be minimized to device replacement or repair. In many situations, patients can effectively treat and manage their SRBD at home with a device such as the myTAP; it is the interface with their Dental Sleep Medicine professional for diagnosis, treatment, guidance, and follow-up that will be key in achieving superior outcomes. Clinicians are encouraged to develop a comprehensive approach, utilizing both CPAP and oral appliances, for SRBD evaluation and treatment.

Ramar, Kannan, et al. “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, vol. 11, no. 07, 2015, pp. 773–827., doi:10.5664/ jcsm.4858.

W. Keith Thornton, DDS, is a third generation dentist who practiced restorative dentistry for 40 years in Dallas. His practice is limited to the treatment of airway and breathing disorders. He is a member of nine different dental and medical organizations and has had numerous leadership positions. He has been a member of the American Academy of Dental Sleep Medicine since 1993 and was an original Diplomate of the American Board of Dental Sleep Medicine. He is a visiting faculty member at A&M College of Dentistry, and is a consultant to the Army, Navy, Air Force and the VA. He has developed a number of medical devices that treat snoring and obstructive sleep apnea and has 72 issued patents. He is the founder, owner, CEO and chief technical officer for Airway Technologies, Inc.

36 DSP | Summer 2020

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CONTINUING education

Telemedicine: It’s About Time by Jagdeep Bijwadia, MD, MBA, D.ABDSM

Educational Aims

Telemedicine is a disruptive force in medicine with significant potential to increase access to care, relieve pressure from an overburdened system, and reduce overall healthcare costs. It has unique indications for use in dental sleep practices including sleep testing and initial consultations. This article will help readers understand the different types of telemedicine, workflow options, legal considerations, and payor guidelines so practitioners are positioned to make informed decisions about telemedicine’s implications for their practices.

Expected Outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 43 or online to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will: 1. Understand the definition of telemedicine 2. Know the regulatory limitations of telemedicine in a dental sleep practice 3. Comprehend the basics of payor requirements for proper telemedicine utilization 4. Have insights into possible workflows utilizing telemedicine for sleep testing, consultations, and other appointments

38 DSP | Summer 2020

elemedicine has experienced accelerated growth and as evidenced by the current COVID19 crisis, it is a powerful resource that enables the disruption of healthcare delivery.1

Telehealth and telemedicine are terms often used interchangeably, but if one is a purist then the term telemedicine is really a subset of telehealth. Telehealth encompasses all health-related uses of communications technology. Telemedicine specifically applies to the use of this technology for clinical applications. The idea that technology can be used to take care of patients at a distance is not new.2 Radiology was one of the first specialties to adopt to this idea as early as the 1950s. Hospitals around Montreal had a teleradiology system in place sharing images with radiologists. Many specialties have since adopted telemedicine including dermatology, psychi-

CONTINUING education atry, oncology, and ophthalmology. The list continues to expand. The most important event in telemedicine was the introduction of video-teleconferencing into the healthcare environment. Video-teleconferencing was originally envisioned as a tool to facilitate business meetings between people separated by geographical distance. As costs declined and cloud technologies became more robust, the quality and stability of teleconference software became suitable for medical applications. Telemedicine was first deployed in the early 1970s to reach rural areas where medical care was sparse. Governmental agencies began investing heavily in this technology. NASA took an active early role in the program to design and test the technology that linked rural patients in mobile support units with physicians at Indian Health Service hospitals in Arizona. It was quickly evident that this technology could be used in urban populations with healthcare shortages, or as a tool to respond to medical emergencies. While telemedicine was originally designed to help people with poor access to care, it is now increasingly becoming a common path to routine health care in a variety of clinical settings. More and more, it is utilized as a convenient and inexpensive alternative to traditional in-person visits. Existing telehealth infrastructure is now being leveraged to respond to the COVID-19 crisis in the US in unprecedented ways. A recent article in the New England Journal of Medicine uses the term “forward triage” to describe home-based telemedicine visits, enabling medical staff to “presort” patients prior to their arrival in urgent care and emergency rooms. This frees up vital resources while protecting both patients and healthcare workers from exposure. Teledoc and America Well, two large public telemedicine platforms, have ramped up their capabilities to address this urgent need. Their staff practitioners are able to triage patients at home who are worried they may have COVID-19 symptoms. ICUs are increasingly using telemedicine (e-ICU) to take care of critically ill COVID-19 patients. Using telemedicine platforms, ICU staff at central locations can monitor patients across one or several ICUs allowing real time examination and monitoring of various physiological data points like cardiac devices

and ventilators. This conserves vital critical care, sub-specialist, and nursing resources, increasing medical system capacity while minimizing exposure.

Types of Telemedicine

The most standard form of telemedicine, real-time synchronous consultations, requires live interaction between a health professional and a patient using both audio and video communication. By contrast, “store and forward” strategies involve collecting data that is reviewed later by a professional. These strategies are common in radiology or pathology, where even traditional consultations are asynchronous. Lastly, remote patient monitoring is a form of homecare telehealth where patients use mobile medical devices and technology to gather patient-generated health data such as blood pressure, oxygen saturation, respiratory rate and send it to healthcare professionals who review the data and communicate back with the patients to direct their care.

As evidenced by the current COVID-19 crisis, it is a powerful resource that enables the disruption of healthcare delivery.

Pros and Cons

The primary advantage of telemedicine is its ability to expand the reach of healthcare services beyond the constraints of physical distance. It increases accessibility to care for patients both in terms of geographic reach as well as access to a variety of specialties that may not be readily available. For example, a rural hospital lacking sleep medicine specialists may employ a telemedicine solution to address that need. Several studies confirm that patient engagement and satisfaction is higher when using telemedicine compared to traditional visits.3 Since the overhead costs of telemedicine

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.

DentalSleepPractice.com

CONTINUING education are lower, the cost of care is often reduced, and several large insurers cover the cost and have incentive programs that encourage patients to use telemedicine platforms instead of urgent care or emergency room visits. Not all medical care can be provided using telemedicine, but the standard of care using telemedicine is equal to in person visits. In a recent Spanish study sleep apnea management via telemedicine was compared to clinic-based care. There was no difference in treatment outcomes or patient satisfaction.4 All state Medical boards hold practitioners to the same standard of care as provided in person. Like any new technology, telemedicine is not without its challenges. Utilizing telemedicine does require some degree of technical proficiency, and some populations (particularly the very elderly) may find it difficult to access. There also have been concerns raised about continuity of care, since patients may not have continuing relationships but rather just episodic visits for example to take care of an acute medical question. As telemedicine matures and patients get accustomed to the technology it is likely that virtual care may become a more suitable norm for long term doctor patient interactions. One of the challenges to patient adoption of telemedicine is the reimbursement for home-based visits. Insurers have been slow to respond to the new technologies and therefore patients are often required to pay for home-based visits out of pocket. Along

40 DSP | Summer 2020

with the reimbursement challenges, regulatory issues are also a challenge and requirements often vary by state, complicating efforts to set up effective multi-state networks.

Legal and Regulatory Considerations

The Center for Connected Health Policy’s (CCHP) Spring 2019 report “State Telehealth Laws and Reimbursement Policies” offers policymakers, health advocates, and other interested healthcare professionals a summary guide of telehealth-related policies, laws, and regulations for all 50 states. Many states are beginning to expand telehealth reimbursement, yet others continue to create restrictive regulations regarding telehealth services. It is important to check your own state laws regarding telemedicine but there are certainly some principles for which most states have reached a consensus. Most states allow telemedicine consults when conducted via HIPAA secure audio-video platforms. Email, telephone, and fax are rarely acceptable forms of delivery unless they are in conjunction with some other type of system. Many states are either silent on or explicitly exclude email, telephone, and fax options, from the definition of telehealth and/or telemedicine Some state’s programs allow and reimburse for store and forward telemedicine and yet others do the same for remote patient monitoring. Six state Medicaid programs (Alaska, Arizona, Maryland, Minnesota, Virginia and Washington) reimburse for each, although certain limitations apply. Thirty-nine states currently require some sort of patient consent for telemedicine. Most states require the consulting practitioner to be licensed in the state in which the patient is seen. There are several states that issue special licenses or certificates related to telehealth. The licenses could allow an out-of-state provider to render services via telemedicine in a state where they are not located. Twenty-nine states and one jurisdiction (D.C.) have adopted the Federation of State Medical Boards’ (FSMB) Interstate Medical Licensure Compact (IMLC) in its place. The IMLC allows for an Interstate Commission to form an expedited licensure process for licensed physicians to apply for licenses in other states. Most states allow online prescribing for treatment once a telemedicine consultation

CONTINUING education has been completed. More stringent policies typically exist restricting practitioners from prescribing controlled substances through telehealth. With the COVID-19 pandemic, Medicare has significantly expanded the use of telemedicine and relaxed some HIPAA regulations as well as the restrictions around site of origin to combat the surge in need for access to medical consultation while maintaining social distancing strategies.

Reimbursement Considerations

Prior to the current COVID-19 pandemic, Medicare policies supported reimbursement for telemedicine with some significant restrictions. For example, Medicare would reimburse for telehealth services offered by a provider at a distant site if the Medicare beneficiary was at an originating site in a designated healthcare shortage area. Examples of qualifying originating sites include physician offices in rural areas, hospitals, critical access hospitals, rural heath clinics, federally qualified heath centers hospital-based dialysis centers, skilled nursing facilities, and community mental health centers. There would be no reimbursement if a patient was in their own home setting. Private payers’ reimbursement policies vary greatly. The big five (Aetna, Cigna, United, Blue Cross Blue Shield, Humana and United Healthcare) all offer some sort of coverage for telemedicine. How much each payer reimbursed depends on the policy in that state (many states have parity laws that mandate equal reimbursement for telemedicine and in person visits) and the individual policy terms.

Telemedicine and Dental Sleep Medicine

From diagnostic options to the various treatment modalities, sleep medicine is a technology-driven medical specialty. The American Academy of Sleep Medicine (AASM) is highly supportive of the use of telemedicine.5 In January 2016, AASM officially launched Sleep TM, a telemedicine platform that was designed for the sleep field and subsequently began developing multiple resources and educational opportunities to equip sleep specialists with the tools to implement a telemedicine program. AASM also tracks and supports tele-

medicine at the state and federal level. With the advent of home sleep testing, the patient journey from screening to consultation and testing can be seamlessly completed within the patient’s own home patient home. A common treatment pathway for dentists is to identify a patient at risk for sleep disordered breathing in the practice and engage them in a conversation about the dangers of undiagnosed sleep apnea and the positive impacts treatment could have on the patient’s overall health. Patients are then referred to the local sleep physician for further workup. Often, patient interest in seeking a diagnosis wanes as the patient leaves the dental office and encounters long wait times for an appointment with a sleep specialist. Diagnosis usually involves trips to an expensive sleep center and CPAP is often the only treatment offered even when mild to moderate sleep apnea is identified and the patient would clearly prefer alternative management. Getting to a diagnosis and a dental device treatment option when clinically indicated can be easily pursued with better dentist-physician collaboration, taking patient choice into account, and leveraging telemedicine with home sleep testing technologies. A typical patient journey using a telemedicine platform involves the dental front office scheduling a telemedicine consult with the patient as soon as they are identified as at risk in the dental office. Within a day or two the patient has a video consultation with a board-certified sleep specialist or trained nurse practitioner who can order a home-based sleep test. Guidelines for a comprehensive sleep telemedicine consult are detailed in an AASM telemedicine position paper. Once the home sleep test results are available, the prescription for a dental device is immediately available to the dentist with all the supporting consultation, testing, and other documentation needed for reimbursement submission to a payor. If CPAP is required, the sleep physician’s practice can arrange for this and follow the patient’s progress. Advantages of such a workflow are faster turnaround times (typically two to three weeks), higher patient engagement and satisfaction, lower overall costs, and close collaboration between the dentists and the physicians with a strong focus on both patient choice and wellness.

From diagnostic options to the various treatment modalities, sleep medicine is a technology-driven medical specialty. The American Academy of Sleep Medicine is highly supportive of the use of telemedicine.

DentalSleepPractice.com

CONTINUING education Important Criteria When Choosing a Telemedicine Partner

• The platform should be HIPAA secure, user-friendly, and easily facilitate any home-based treatments that may be required. • Ensure the workflow can be easily integrated into your current practice. • Be certain you understand how consultation and sleep testing results will be communicated back to your office. • The telemedicine practice should be able to help with letters of medical necessity or peer review with insurers. • Compatibility with commonly available browsers and devices including mobile devices is critical. • A telemedicine platform should provide some analytics and visibility so that you can track patients’ progress on a realtime dashboard. • The overall cost to the patient. • Pathways for followup for patients who are not candidates for dental devices should be in place so that comprehensive care is provided.

1. 2. 3. 4. 5.

Further follow-up care, including efficacy testing, referral back to the dentist for patients who subsequently fail a CPAP therapy trial, follow-up consultations for patients who do not respond adequately to dental device adjustment, and chronic care coordination, could all be part of ongoing collaboration. Working with local physicians is obviously still important, however telemedicine can and should be an important adjunct to a dental sleep practice, especially those that have difficulty finding local sleep physicians, those who have patients traveling from long distance, or those who prefer the convenience of home-based care. While most payors have not historically paid for home-based telemedicine visits, almost all of them now recognize telemedicine visits as an option for patients and will pay for subsequent home sleep testing and dental devices that are prescribed. Medicare is an exception and requires a face to face visit as a prerequisite to reimbursing for a dental device. The present COVID-19 pandemic has created huge challenges for dentists in the dental sleep arena. There have been concerns about aerosolization and increased risks to contacts around COVID-positive patients on CPAP, making dental devices an attractive alternative in some cases. There are several innovative ways in which telemedicine is being leveraged to care for patients by some leading sleep dentists paving the way for others to follow their example. Patients at risk for OSA are first medically diagnosed by a sleep specialist using telemedicine consultation and home sleep testing. Dentists then complete all follow up visits, including seating of the custom device and using a telemedicine platform after an initial in-person visit to obtain the bite registration and dental exam. Dentists may also consider telemedicine consults to teach patients how to fit titratable temporary devices as a temporary measure during the COVID-19 pandemic, with the intention of bringing these patients back into

the office for a custom device when conditions allow.

Choosing a Telemedicine Provider

There are some important criteria to consider when choosing a telemedicine partner. The platform should be HIPAA secure, user-friendly, and easily facilitate any homebased treatments that may be required. Ensure the workflow can be easily integrated into your current practice. Be certain you understand how consultation and sleep testing results will be communicated back to your office. The telemedicine practice should be able to help with letters of medical necessity or peer review with insurers. Compatibility with commonly available browsers and devices including mobile devices is critical. A telemedicine platform should provide some analytics and visibility so that you can track patients’ progress through the various steps on a real-time dashboard. Make sure you or one of your staff go through the consultation and testing process before you move forward. This will allow you to instruct your patients well and give you a sense of how user-friendly the platform is. The overall cost to the patient, should be taken into consideration as well. Like any other referral relationship make sure you take the opportunity to talk to some of the physicians in the telemedicine practice and understand their approaches to treatment. Pathways for follow-up for patients who are not candidates for dental devices should be in place so that comprehensive care is provided.

Summary

Telemedicine is a cost effective, scalable, and patient-centered method to deliver care in many settings. The COVID-19 pandemic has likely moved the field of telemedicine forward in terms of recognition, accessibility, and from a regulatory perspective. It is likely that telemedicine will become a routine part of medicine and continue offering unique opportunities to streamline and enhance the practice of dental sleep medicine.

Virtually Perfect? Telemedicine for Covid-19. Hollander JE, Carr BG. N Engl J Med. 2020 Mar 11. Telemedicine: Emerging e-medicine SK Mun, JW Turner – Annual Review of Biomedical Engineering, 1999 – annualreviews.org Comparing Patients’ Experiences with Electronic and Traditional Consultation: Results from a Multisite Survey. Ackerman SL, Gleason N, Shipman SA. J Gen Intern Med. 2020 Feb 19. doi: 10.1007/s11606-020-05703-7. Reliability of telemedicine in the diagnosis and treatment of sleep apnea syndrome. Coma-Del-Corral MJ, Alonso-Álvarez ML, Allende M, Cordero J, Ordax E, Masa F, Terán-Santos J. Telemed J E Health. 2013 Jan;19(1):7-12. doi: 10.1089/tmj.2012.0007. Epub 2012 Nov 27. 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. doi: 10.5664/jcsm.5098.

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CONTINUING education

Continuing Education Test

CE CREDITS

Certificate Details

REF: DSP Summer 2020

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Telemedicine: It’s About Time by Jagdeep Bijwadia, MD, MBA, D.ABDSM 1. Telemedicine can be considered a subset of telehealth. a. True b. False 2. One of the first specialties to adopt telemedicine was _______. a. Surgery b. Endocrinology c. Radiology 3. Types of telemedicine include _______. a. Synchronous, asynchronous and remote patient monitoring b. Individual and Group Telemedicine c. Educational, Instructional and Clinical Telemedicine 4. Telemedicine is reimbursed by Medicare with some restrictions. a. True b. False 5. Telemedicine visits require patient consent in all states. a. True b. False

6. Dentists can collaborate with Physicians using telemedicine for _______. a. Initial consults and follow up visits, b. Ordering home sleep testing c. To obtain prescriptions for dental device treatment d. All of the above 7. Physicians must be licensed ______. a. in their own state as well as the state in which the patient is seen b. in at least 1 specialty to see patients via telemedicine c. in only their own state with no concern for the state in which the patient is seen d. none of the above 8. Parity Laws in telemedicine refer to ______. a. Requirement for Payers to pay the same amounts for in person and telemedicine visits b. Requirement for telemedicine visits to follow the same standard of care as in person visit c. Mandate that cash pay telemedicine

visits have the same rate as insurance based charges 9. COVID-19 Medicare change includes _______. a. Expansion of use of telemedicine allowing physicians to consult across state lines b. Relaxation of HIPAA requirements when performing telemedicine consults c. Removal of restrictions around patients’ site of origin d. All of the above 10. Sleep TM is ______. a. A telemedicine platform supported by the AASM b. A type of home sleep testing monitor c. A publication that is dedicated to telemedicine news 11. Synchronous telemedicine requires simultaneous ________. a. audio and video technology b. Use of an EMR and paper charts c. PAP and OAT therapies d. None of the above

DentalSleepPractice.com

MEDICALinsight

Should I add TMD care to my DSM practice? by Jamison Spencer, DMD, MS

ow I know that your knee jerk reaction will be “absolutely not!” but perhaps bear with me for a minute. As I write this we’re going through “a little crisis.” Lots of my colleagues are closed down, other than perhaps seeing dental emergencies. While some initially rationalized, “hey, sleep apnea IS an emergency” the Governor of their state, and their dental association and board, didn’t tend to think so. But patients with various TMJ disorders ARE people who go to the ER to see why “their ear ache” isn’t getting any better, or how come they can’t open their mouth as wide anymore. As such, during the crisis, our practices sent out letters to our colleagues to help them

recognize two of the main TMJ problems that could result in a patient seeking unnecessary medical care and thus further clogging the strained system. I’ll share part of that letter here, and maybe you’ll even learn something. But the point is do you really want to only focus on sleep? I know it sounded pretty awesome when you were doing general dentistry and physically beat up. And treating sleep apnea IS awesome! But many of the skills that you’ve developed in order to help those with sleep apnea can be utilized to help people with various TMJ problems… and it’s kind of nice to have more than one “product” sometimes, right? Here’s the letter we sent out:

To our esteemed colleagues, At the Center for Sleep Apnea and TMJ we are acutely aware of the broad effects that Covid-19 is having on all of our colleagues and our collective patients, their families and our communities. Many in our communities are highly concerned due to the uncertainty. As you are aware, emotional stress has been linked to increased TMJ disorders and craniofacial pain and dysfunction. The ADA has asked us as dentists to do anything we can to reduce the level of patients who might present to emergency rooms and other medical providers with dental related problems. In an effort to perhaps provide some level of relief of medical resources, albeit it small in scope, we would like to provide you with simple guidelines for tentative diagnosis of 2 of the most common TMJ disorders that could result in a patient seeking medical/emergency care. These conditions are retrodiscitis, or an inflammation of the posterior TMJ capsular tissues, and non-reducing disc displacement, also known as a “closed lock.” Retrodiscitis: • Typically there will be a history of recent trauma, however this “trauma” could also be simply from increased clenching/ grinding of the teeth. • The patient will usually report pain in or over the TMJ, usually unilaterally. This may also present as or be perceived as an ear ache, which leads the patient to believe they have an ear infection. • Typically the patient will report or present with an acute malocclusion, a posterior open bite, on the same side that they have the TMJ/ear pain. • Usually the patient will report pain upon trying to occlude, although sometimes chewing on the same side as the pain will be LESS painful (due to the food resulting in space between the teeth and now allowing for full seating of the condyle). continued

44 DSP | Summer 2020

MEDICALinsight Non-Reducing Disc Displacement: • The patient will typically report a history of their jaw popping and clicking, sometimes for years. • They will typically report occasional “locking episodes” where their jaw gets stuck for a few seconds to a few minutes. Often they will report that they sometimes wake up with their jaw stuck, but are quickly able to get their jaw to open further, typically with a pop or a click. • The patient will often “wake up locked,” unable to open more than 2 fingers between their anterior teeth. It is usually at this point that the patient feels that an emergency condition has developed and will seek out care. This is often very frightening to the patient. In each of these cases, we are able to at least make a tentative diagnosis via a telemedicine/video consult. We have recently put HIPAA compliant telemedicine protocols in place so that we can virtually “see” these patients without them needing to travel to our office unless it is absolutely necessary. In the case of retrodiscitis it is common for us to be able to treat this condition with very conservative methods which may not even require an office visit. In the case of a non-reducing disc displacement, typically we refer the patient for an MRI to confirm diagnosis. Time is of the essence. The longer they are locked the more likely they will stay locked. The procedure to “unlock” the disc displacement requires an intra-articular injection and immediate fitting of a temporary splint, which obviously would require an office visit. Again, we hope that this relatively simple accommodation for any patient that you might have who contacts your office with one of these relatively common TMJ disorders might reduce the odds of these patients seeking medical care and placing a greater burden on the already strained system. We also hope that this will help those of you who have patients who must travel a great distance to come to our office as using this telemedicine protocol we will be able to know at a fairly high level which patients actually will need to come in and who may stay home. This offer to provide telemedicine consults for your patients will continue for as long as needed. Should you have any questions please feel free to reach out via phone or email. We hope that you and your family are well, and hope that this crisis will pass as quickly as possible. Sincerely,

I really, really, really hope that by the time you read this that the Covid-19 crisis has significantly improved and that life has returned to somewhat normal. Although that “normal” will be a “new normal.” Tele-health is going to be something that we now embrace. It is going to allow us to see patients easier, faster, more conveniently and at less expense, and to help catch things earlier before they become chronic. TMD and DSM will both benefit from telehealth. The patients will still ultimately need to physically see us, but we’ll know they are in the right place before they walk in the door. If you’ve put off TMD for your whole career because you didn’t feel that the ZERO to a few hours of lecture you received in dental school were enough to make you competent (and you were right), now might be the right time to consider acquiring the skills necessary to provide an accurate diagnosis and a conservative and effective treatment plan. And, as a bonus, the more you understand about TMJ problems the less scared you’ll be

of oral appliance therapy side effects and the better you’ll be able to help your sleep apnea patients. It’s a win-win!

Jamison Spencer, DMD, MS, is the director of Dental Sleep Medicine for the Center for Sleep Apnea and TMJ, in Boise, Idaho and Salt Lake City, Utah. Dr. Spencer is the Past-President of the American Academy of Craniofacial Pain (AACP), a Diplomate of the American Board of Craniofacial Pain, a Diplomate of the American Board of Dental Sleep Medicine, a Diplomate of the American Board of Craniofacial Dental Sleep Medicine and has a Masters in Craniofacial Pain from Tufts University. He taught head and neck anatomy at Boise State University, is adjunct faculty at the University of the Pacific School of Dentistry, and the University of North Carolina at Chapel Hill. Dr. Spencer created Spencer Study Club, an online education, mentoring and implementation program to help dentists and their teams help more of their patients with sleep apnea and TMJ disorders. Dr. Spencer now lives in Pleasant View, Utah with his wife, Jennifer, and their 3 children of 6 who are still at home. Dr. Spencer can be reached at Jamison@JamisonSpencer.com, 208.861.5687 or www. JamisonSpencer.com.

DentalSleepPractice.com

BILLINGblocks

Is Unethical Billing Preventing Quality Sleep? by Randy Curran

t is paramount that providers understand the definition of each medical code they bill using their NPI number whether it’s to federal, state, or privately funded insurance plans. As the number of dentists billing medical codes increases, so too will the level of scrutiny applied by payors. Many dental sleep medicine (DSM) practices utilize the services of third-party billing companies to manage their medical claims. Outsourcing medical billing processes is a prudent decision for many practices. The majority of medical billing companies are adept at obtaining maximum reimbursement which improves practice profitability via increased collections and decreased personnel costs that would otherwise be incurred if managing these processes with internal staff. Misinformation abounds when in it comes to ethical coding and billing. Appropriate codes must be used for coinciding procedures. It is unacceptable, unethical, and illegal to bill codes that are not applicable for the procedure performed. Most medical billing companies are extremely competent and follow ethical coding guidelines. However, the onus falls on dentists to ensure that proper codes are being billed under their NPI numbers. This means the proverbial “buck stops with you.” The Department of Justice (DOJ) agrees. Recently the DOJ discovered wrongdoing with a TMD practice in Wisconsin.1 As a coding expert, this tells me that the practice was likely using codes such as 21085 (impression and custom preparation; oral surgical splint), 21089 (unlisted maxillofacial prosthetic procedure), 21110 (application of interdental fixation device for conditions other than fracture or dislocation), or other non-applicable surgical codes. I presume this practice did not know what they were doing was wrong, hence a settlement instead of imprisonment. Unfortunately, this is commonplace in the DSM field where many practices are acting based on misinformation and misplaced trust. Over the years, numerous dental practices have informed me that their third-party billing companies instructed them to use the codes mentioned above to bill for AM Aligners, morning repositioners, TMD occlusal guards, and even impressions. These practices were under the impression that this guidance was correct because their billing companies

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

46 DSP | Summer 2020

told them it was. They were even told that using reduced service modifiers is acceptable, “because it’s hard to find an accurate code.” Medical coding isn’t a game of horseshoes; you can’t just be close enough. It’s more akin to a hand grenade. Being “close enough” can have dire consequences as it did for the Wisconsin practice discussed earlier. Another alarming development that can have significant negative repercussions for practices is the advent of third-party entities billing under dentists’ personal NPI numbers, receiving the Explanation of Benefits (EOB), and then directly paying the dentist. The dentist never even sees their patients’ EOBs. This is extremely concerning and exposes practices to risk and liability that may result in penalties, recoup actions, or worse. Medical insurance fraud accounts for over 70% of fraud in the United States. Lessons can be learned from the misdeeds of DME providers in the early 2000s. Some were billing for prosthetics and supplies for patients they’d never seen and in some cases, the patients weren’t even alive. The DOJ took action which significantly reduced waste and fraud. That same scrutiny may be directed toward the DSM field in the future. This could be a step in the right direction as it can eliminate fraud, save taxpayer dollars, and ensure competitive parity. It should not cause any trepidation if you’ve done your due diligence and you have always coded ethically. If you’re billing the aforementioned codes or a third-party biller is doing it for you – stop immediately. Then purchase a current coding manual or subscribe to a site like www.supercoder.com which costs less than $10 a month. Should this article stop dental practices from treating sleep apnea and billing medical insurance? Absolutely not! Accurate coding and ethical billing practices can lead to highly profitable DSM practices. Do the right thing the right way and the revenue will follow. 1.

“TMJ & Orofacial Pain Treatment Centers of Wisconsin Agree to Pay $1 Million to Resolve False Claims Act Allegations.” The United States Department of Justice, Department of Justice U.S. Attorney’s Office Eastern District of Wisconsin, 15 Jan. 2020, www.justice.gov/usao-edwi/pr/tmj-orofacial-pain-treatmentcenters-wisconsin-agree-pay-1-million-resolve-false-claims.

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ORTHO connection

Increasing airway volume with a removable orthodontic dental appliance: a multi-case report by Theodore R. Belfor, DDS, Michael Philcock, and Scott Simonetti, DDS Introduction

The American Association of Orthodontists White Paper: Obstructive Sleep Apnea and Orthodontics states, under the term “Etiology,” “Obstructive Sleep Apnea occurs as a function of increased collapsibility of the upper airway. The pharyngeal critical closing pressure (Pcrit) is the pressure at which the upper airway collapses. This collapsibility is influenced further by impaired neuromuscular tone.”1 Comparing the size and shape of the pharyngeal airway for Obstructive Sleep Apnea (OSA) patients and non-OSA patients, research shows that the minimum cross-sectional area (min. area) and anterior-posterior (AP) dimension exhibit significant differences. Statistically, the AP dimension and the min. area of the OSA group are significantly smaller than those of the non-OSA group.2,3 These studies confirm that the AP dimension of the airway and the cross-sectional area of the narrowest airway slice in the oropharynx are significantly smaller in OSA patients compared to non-OSA subjects. It is the purpose of this article to demonstrate, through multiple case studies, that dental appliance therapy increases the pharyngeal airway size and shape, which may be related to improved airway tone and reduced collapsibility. Table 1: Case 1 Results Pre-treatment

Post-treatment

Difference

%Change

Airway Volume

13550.81 mm3

28044.49 mm3

14493.68 mm3

106.96

Minimum Cross-sectional Area

47.88 mm2

233.28 mm2

185.40 mm2

387.22

Figure 1: Case 1 – Pre- and post-treatment airways. (A) Rendering of the pre-treatment airway in the coronal orientation. (B) Rendering of the pre-treatment airway in the sagittal orientation. (C) Pre-treatment airway at the narrowest axial cross-sectional area. (D) Endoscopic rendering of the internal airway in the pre-treatment scan. (E) Rendering of the post-treatment airway in the coronal orientation, the increase in airway dimension is shown in red. (F) Rendering of the post-treatment airway in the coronal orientation, the increase in airway dimension is shown in red. (G) Post-treatment at the corresponding location to the narrowest pre-treatment axial cross-sectional area, the increase airway area is shown in red. (H) Endoscopic rendering of the internal airway in the post-treatment scan.

48 DSP | Summer 2020

Methods

A cone beam computerized tomographic (CBCT) scan was taken of the patient before treatment and again after 12 or 24 months. Upper and lower dental models were made and Homeoblock™ dental appliances were fabricated for the patient.4,5,6 The Homeoblock utilizes an orthodontic expansion screw along with Unilateral Bite Block Technology™. The unilateral 5mm bite block is placed on the second bicuspid and first molar on the less developed side of the face, which is the side that can have a deeper nasolabial depression or lower eye, thinner upper lip, or deeper pre-jowl region. The appliances were worn a maximum of 12 hours each day (mainly during sleep) for up to 24 months. The patient was instructed to advance the expansion screw 0.125 mm (1/4 turn) each week. The patient returned periodically for minor adjustments. Independent evaluation of the pre- and post-treatment CBCT scans was performed by an analysis technician using Analyze 14.0 software (Biomedical Imaging Resource, Mayo Clinic, MN, USA) to obtain airway volume and minimum cross-sectional area measurements. Pre- and post-treatment scans were first co-registered and transformed using a rigid mutual information maximization algorithm. Next, the pre-treatment and transformed post-treatment scans were used as an input for segmentation. Upper airway segmentation was achieved by setting limits using morphological landmarks common to both input volumes; the epiglottis as a lower limit and the palatine bone as the upper limit. A 3D region-growing algorithm was then utilized to isolate the pre-treatment and post-treatment airways. The resulting airway volumes and axial cross-sectional areas at the narrowest point in the pre-treatment and corresponding location in the post-treatment airway were calculated.

ORTHOconnection Case Study 1

Background: A 35-year-old male with moderate sleep apnea, was referred by a board-certified sleep physician as he did not want to wear a CPAP. Results: Table 1 and Figure 1. Outcome: Treatment decreased the patient’s Apnea Hypopnea Index from 27 to 5. The patient is no longer required to wear a CPAP.

Case Study 2

Background: A 72-year-old patient presented with the complaint of being tired in the morning. Results: Table 2 and Figure 2. Outcome: Post-treatment the patient states, “I am able to bring my jaw forward, and my breathing has become deeper. I feel so much better.”

Case Study 3

Background: A 58-year-old male was treated after reporting problems sleeping due to snoring, headaches, and overall body pain. Results: Table 3 and Figure 3. Outcome: After treatment the patient reports, “I feel so much better, no more headaches.”

Discussion

The collapse of the pharyngeal airway during sleep has serious health consequences such as disrupted sleep, reduce oxygen saturation levels, and OSA. The physiological mechanism causing such conditions is closely related to flow in tubes. Airflow modeling in Starling resistors has revealed a variety of dynamics involved in compressed collapsible tube systems such as our airway.7 The base of the tongue represents the “bottleneck” region in the human airway, and constriction in this region can have adverse effects both upstream and downstream from this point. Both inspiratory and expiratory flow limitations can be created by a lack of space at the base of the tongue. Turbulent airflow increases tongue collapsibility, further exasperating the problem and a smaller, less toned muscular airway reduces airway volume with a decrease in patient’s Pcrit, increasing the number of apneic events.8 The presented timeline case studies demonstrate that it may be possible to remodel the muscular tube, which is the pharyngeal airway. Both the pre-treatment and post-treat-

Table 2: Case 2 Results Pre-treatment

Post-treatment

Difference

Airway Volume

23894.68 mm

27536.03 mm

3641.35 mm

Minimum Cross-sectional Area

180.45 mm

205.38 mm

24.93 mm

%Change 3

15.24 13.82

Figure 2: Case 2 – Pre- and post-treatment airways. (A) Rendering of the pre-treatment airway in the coronal orientation. (B) Rendering of the pre-treatment airway in the sagittal orientation. (C) Pre-treatment airway at the narrowest axial cross-sectional area. (D) Endoscopic rendering of the internal airway in the pre-treatment scan. (E) Rendering of the post-treatment airway in the coronal orientation, the increase in airway dimension is shown in red. (F) Rendering of the post-treatment airway in the coronal orientation, the increase in airway dimension is shown in red. (G) Post-treatment at the corresponding location to the narrowest pre-treatment axial cross-sectional area, the increase airway area is shown in red. (H) Endoscopic rendering of the internal airway in the post-treatment scan.

Table 3: Case 3 Results Pre-treatment

Post-treatment

Difference

Airway Volume

13105.29 mm

22604.62 mm

9499.33 mm

Minimum Cross-sectional Area

81.81 mm

171.90 mm

90.09 mm

%Change 3

72.48 110.12

Figure 3: Case 3 – Pre- and post-treatment airways. (A) Rendering of the pre-treatment airway in the coronal orientation. (B) Rendering of the pre-treatment airway in the sagittal orientation. (C) Pre-treatment airway at the narrowest axial cross-sectional area. (D) Endoscopic rendering of the internal airway in the pre-treatment scan. (E) Rendering of the post-treatment airway in the coronal orientation, the increase in airway dimension is shown in red. (F) Rendering of the post-treatment airway in the coronal orientation, the increase in airway dimension is shown in red. (G) Post-treatment at the corresponding location to the narrowest pre-treatment axial cross-sectional area, the increase airway area is shown in red. (H) Endoscopic rendering of the internal airway in the post-treatment scan.

DentalSleepPractice.com

ORTHOconnection ment images were obtained without the appliance in place. The increases in airway volume were also measured and calculated without the appliance in place. The traditional treatments for OSA (CPAP and Mandibular Advancement Devices) serve to open the airway only while being worn and have not yet demonstrated increased airway volume while not utilizing the devices. Although these treatments are intended for nocturnal use, the presented data demonstrate anatomical improvements while awake, when not wearing the appliance. The case studies show an increase in volume, especially in the area posterior to the tongue and in the region bounded by the back and side walls of the throat. The increase in airway volume provides greater airflow and reduces the “bottleneck” - the main source of turbulence and resistance behind the tongue. We hypothesize that the measurable increases in airway volume are obtained in several ways, due to the design of the oral appli-

ance. 1) By altering swallowing patterns while wearing the appliance, it acts as a tongue trainer. The appliance provides a platform that engages the tongue near the roof of the mouth when swallowing. It is postulated this action eventually retrains the tongue during waking hours while toning the muscles at the base of the tongue. This myofunctional therapy occurs every night while the patient sleeps and helps to tone the muscles that raise the tongue, such as the stylohyoid, mylohyoid muscles, genioglossus, and hyoglossus muscles. Furthermore, the pharyngeal constrictor muscles that comprise the airway have been toned by the actions of the lips and cheeks while wearing the appliance. 2) The design of the appliance helps the obicularis oris and buccinator to function in a way that may help stimulate the superior pharyngeal constrictor and help tone the muscle. The buccinator is joined to the superior pharyngeal constrictor by the pterygomandibular raphe, and light stimulation of these muscles may help provide the toning evident in the presented data.

Conclusion Theodore R. Belfor, DDS, is a graduate of New York University College of Dentistry, a Senior Certified Instructor for the International Association for Orthodontics (IAO) and has been in private practice for more than 40 years. Since 2001, Dr. Belfor has specialized in patient treatment with the Homeoblock™ orthopedic/orthodontic appliance designed with the Unilateral Bite Block technology®, for face and airway development in adults. Dr. Belfor has been lecturing, teaching and training dentists with the Homeoblock™ and his unique diagnostic protocol for more than 18 years worldwide. His work is devoted to understanding the causes of sleep and breathing disorders through individual patient craniofacial analysis. Dr. Belfor has been published in numerous journals. He can be reached through his site at drtheodorebelfor.com. Michael Philcock is a product manager for AnalyzeDirect. He has more than 15 years of experience in the processing and analysis of biomedical imaging data for a wide range of biological applications in the healthcare, life sciences, pharmaceutical, and biotech industries. Scott Simonetti, DDS, earned his Bachelor of Science in Nutritional Sciences from Cornell University and then attended the University at Buffalo School of Dental Medicine where he earned his DDS degree. Dr. Simonetti has been in private general practice on Long Island since 2001. He is the inventor of the FDA cleared and patented custom oral orthotic, The POD®. Dr. Simonetti has lectured at multiple continuing education programs and has appeared on national radio programs and blogs, discussing stem cells, nitric oxide, mitochondria, intermittent hypoxia and disordered breathing. He is the Co-Founder and CEO of Advanced Facialdontics LLC, a company that designs and develops novel oral orthotics. He has presented research to the Department of Defense at the Military System Health Research Symposium in Kissimmee, Florida and has a passion to help military personnel and first responders.

50 DSP | Summer 2020

The results that we see here can be related to the simple concept that form follows function. By improving the function of swallowing by toning the muscles while sleeping, we can improve the form of the pharyngeal airway while awake. Dentists may play an important role in the detection of OSA in patients through careful oropharyngeal examination in routine dental treatment. It is postulated that this treatment can reduce or delay the onset of OSA in some individuals and needs to be studied in controlled clinical trials. 1. 2.

4. 5. 6.

American Association of Orthodontists White Paper: Obstructive Sleep Apnea and Orthodontics Barrera E J, Pau CY, Forest VI et al. Anatomic measures of upper airway structures in obstructive sleep apnea. World Journal of Otorhinolaryngology Head and Neck Surg. 2017 Jun; 3(2): 85–91. Svaza J, Skagers A, Cakarne D, Upper airway sagittal dimensions in obstructive apnea (OSA) patients and severity of the disease. Stomatology. 2011;13 (4):123-7 Belfor, TR Epigenetic orthodontics. Face and airway development vol. 18. NYSDJ Nov 2010 Belfor TR, Singh GD Developing dental symmetry using an intraoral device. A case report JCD vol. 20 (2) 2004 Belfor TR, Mahony D Improving the adult dental arch, and airway, through bioengineering and dentofacial orthopedics. Aest Dent Today vol. 5 (3) May 2011 Bertram CD, Raymond CJ, Pedley TJ. Application of nonlinear dynamics concepts to the analysis of self-excited oscillations of a collapsible tube conveying a fluid. Journal of Fluids and Structures, vol. 5, no.4, pp. 391-426, 1991. Rasani MR, Inthavong K, Tu JY. Simulation of pharyngeal airway Interaction with air flow using a low-Re turbulence model. Modeling and Simulation in Engineering. volume 2011

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PRODUCTspotlight

Pending Restorative Work But Need Oral Appliance Therapy?

ll practices, even full-time sleep practices, have patients that present for sleep apnea treatment while in the process of having restorative dentistry done. Doctors usually have a hard-acrylic sleep device made so they can retro-fit the device to the restorative work, once completed by their dentist at a later date. This is very labor intensive, distorts the integrity of the OSA device, and requires valuable chair time that could be spent with new patients. So, how do practices avoid or eliminate these costly remakes and still get the patient an oral device that will work in these restorative cases?

Figure 1: DynaFlex Milled Adjustable Herbst - Accu-Fit

Figure 2: DynaFlex Milled Dorsal - Accu-Fit

52 DSP | Summer 2020

DynaFlex has the answer – a patented thermal-plastic liner called “Accu-Fit™.” The DynaFlex® Accu-Fit™ liner is easily adaptable (and re-adaptable) to fit new restorative work. This liner allows adaptation in mere seconds rather than minutes or hours. Simply take your impressions or scans and a bite, like usual. On the Rx you are submitting with the case, indicate which teeth are going to be implanted or restored. DynaFlex’s state-of-the-art Dental Sleep Medicine Laboratory will then add temporary pontics to the areas that have no remaining teeth in place or build up the current tooth or teeth for future restorations. This gives the extra space needed for those future restorations and avoids having to grind or manipulate the sleep device, saving a tremendous amount of chair time while avoiding costly remakes. Our skilled technicians are trained to adequately adapt the device as needed and will leave necessary spacing around the dentition to allow for further re-fitting capabilities. The DynaFlex® Accu-Fit™ material is so advanced and malleable that you can even retro-fit over a 3-4unit bridge within a matter of seconds. It’s the ultimate material/appliance combination for your patients in the process of getting restorative work done or planning to do so in the near future. The DynaFlex Accu-Fit™ liner can be applied to both the Adjustable Herbst (Fig. 1) and the DynaFlex® Dorsal devices (Fig. 2), including our CAD/CAM Milled Devices. The device already comes pre-fitted to the working models, making delivery as simple as possible. We recommend placing the liner in 160-degree water for 5-7 seconds to soften the material for a smooth path of insertion. Patients with retention concerns or significant crowding are also great candidates for a device with the Accu-Fit™ liner, allowing for a smooth and secure fit. No matter the circumstance, DynaFlex® Accu-Fit™ liner gives your office the confidence of knowing that your sleep apnea patients will be leaving with a perfectly fitting device the day of delivery.

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PRACTICALtips

You Shouldn’t Have to Adjust by Alexander T. Vaughan, DDS, MS, D.ABOP, and Michael S. Pagano, DDS, D.ABDSM

n 2019, the American Academy of Dental Sleep Medicine updated the published standards on the definition of an “effective oral appliance.” This paper has been foundational in setting standards for the industry, but we must remember its intent is the minimum standards, not the optimal form. Like most materials and appliances in dentistry, we have an abundance of options with their own advantages and disadvantages, but it’s up to the individual dentist to determine the “best fit” for them and their patients.

nothing less. As a profession, we have unfortunately accepted chairside adjustments as normal. We should ask ourselves, “would we routinely expect to adjust the intaglio of a crown or Invisalign aligners?” Why do we accept this with our MAD? How will these devices meet the needs of millions of people suffering from sleep apnea if the time involved cannot scale proportionally?

When starting our own dedicated DSM practice, we spent a significant amount of time debating which appliances we wanted to be our daily workhorses. Through this process we developed what we feel are criteria that will allow us to move beyond “effective” and into the realm of “practice defining” characteristics.

A mandibular advancement device (MAD) is a Class II medical device regulated by the FDA. As such, the approved instructions for use (IFU) must be followed for use to be considered “on label.” Unless the device IFU include directions for modification (as, for example, the TAP® 3 ThermAcryl® IFU does), any adjustments are “off-label” use. Assuming we provide excellent records, we should expect a perfect fit and accept

One of the great benefits of oral appliance therapy is ease of use and comfort compared to PAP. This mindset should extend to our appliance selection as well. We need to consider the patient experience during adjustment. When evaluating appliances, we found the overwhelming majority have 2 or more points of adjustment, such as bilateral jackscrews, maxillary and mandibular tray configurations, or bilateral bands, straps, or bars. Additionally, many devices require ordering additional pieces after the device has been delivered to the patient. This increases the number of follow-up visits required and the overall cost of therapy. Our search only found two commonly prescribed appliances with a single advancement mechanism and all necessary parts of the device available at delivery without significant additional costs, namely the TAP® line of appliances and the SomnoDent Avant™

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54 DSP | Summer 2020

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PRACTICALtips #3: Manufacturing Partnership Finally, we should consider partnering with a manufacturer that has a comprehensive appliance line. Not only does this allow for multiple appliances to select for the unique needs of each patient, but it also allows for improved dialogue between supplier and dentist. We challenge all manufacturers to meet these standards: 1) First time fit with no chairside adjustments. 2) Single point advancement mechanism with all parts of the device necessary for its use available at delivery. 3) Excellent communication including necessarily delaying cases when in the patient’s best interest due to subpar records from the provider. Satisfying these criteria will result in better patient outcomes, more predictable chair time, and more closely align DSM expectations with those of our medical counterparts.

Alexander T. Vaughan, DDS, MS, D.ABOP, is a board certified orofacial pain specialist and co-founder of Virginia Total Sleep. His practice, located in Richmond, Virginia, is fully dedicated to the specialized treatment of orofacial pain and sleep apnea and was founded on the key pillars of increased access to care through medical insurance billing and digital dentistry. Michael S. Pagano, DDS, D.ABDSM, is an owner of Virginia Total Sleep which is dedicated to the treatment of snoring, sleep apnea, and orofacial pain. Dr. Pagano is a diplomate of the American Board of Dental Sleep Medicine and instructor for the American Academy of Dental Sleep Medicine’s Mastery Program. He is a veteran of the US Army where he helped develop the Army’s Dental Sleep Medicine Mini Residency. He has helped train well over 500 dentists in the field of dental sleep medicine.

CPAP Therapy Comfort and Compliance RemZzzs® CPAP mask liners were created to solve many of the issues people experience while attempting to treat sleep apnea. Robert Rutan, the founder and CEO of Naturs Design, Inc., witnessed first-hand the challenges people with sleep apnea face when his wife, Deborah Rutan, was diagnosed with obstructive sleep apnea. Frustrated and ready to give up on her therapy, Robert made one final attempt to ease Deborah’s pain and frustration. That night, the RemZzzs® liner was born! The patented design of the RemZzzs® liner acts as a barrier between the face and silicone mask cushion, eliminating most of the common problems associated with wearing a CPAP mask. RemZzzs® liners can greatly reduce or eliminate noisy air leaks; assist with comfortably holding the mask in place by reducing slippage; prevent skin irritations and pressure marks associated with sleep apnea masks; and promote healing of suspected deep tissue injury and stage one and two pressure sores. The liners also help absorb facial moisture and oils and allow for the use of bedtime facial products. This revolutionary product is patented in 9 countries and can be used by all ages, from children to the elderly. The liners are made entirely in the United States of a special blend of 100% natural, hypoallergenic, cotton fibers creating a lightweight and breathable liner that is clean, convenient, and disposable. Rutan states, “If we can positively change lives and have people experience the same relief Debbie experienced upon the creation of RemZzzs®, then we feel we are making a difference in the world”. To purchase your 30 day supply, please visit www.remzzzs.com or call (877) 4736999 to receive a FREE 3 day sample.

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56 DSP | Summer 2020

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