Dental Sleep Practice Winter 2019 by MedMark, LLC

Embrace Disruption –

Rewards Come with Adding Technology by John Pasicznyk, DDS

WINTER 2019 | dentalsleeppractice.com

The Oventus O2Vent® Optima Nylon Appliance

by John Viviano, DDS, D.ABDSM

PLUS

CE/Special Feature:

ADA Policy Statement Part 2

Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Jamison Spencer, DMD, MS, et al.

THE MEDLEY SLEEP APPLIANCE

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THE MEDLEY ROD SLEEVE SLEEP APPLIANCE This application 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

SNORING.” —Robert Rogers DMD, DABDSM Inventor of the Medley

This application, 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 This application utilizes a mandibular “pulling” force. The

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INTRODUCTION

The Way Sleep Meetings Should Be Done

n late September, the World Sleep Society held their meeting in beautiful Vancouver, Canada. This five-day event assembled sleep and health volunteers, medical auxiliaries, and licensed medical professionals of every description who are concerned with sleep and sleep-related medical disorders. Over 300 hours of individual talks were presented by hundreds of speakers. There were 12 keynotes and more than 1,100 posters to view. I wanted to be in three places at once. Dentistry was well represented, and, more importantly, well regarded by the whole range of attendees. It seemed Dr. Fernanda Almeida was everywhere, hosting panels, introducing the top researchers and clinicians from around the world, or providing insights from her deep body of work and research. (And hosting a fabulous party!) Dr. Peter Cistulli opened one of his presentations, “Oral appliance therapy for obstructive sleep apnea: Ready for prime time” by asking for hands in the room for physicians, dentists, and ‘other.’ The results I’ve never seen at any other sleep meeting: equal number of hands went up for each group. It’s as if physicians, dentists, respiratory therapists, myofunctional therapists and researchers had something to learn from each other and an interest in working together! Notice the title did not end with a question – it was a declaration by someone who knows about what is real, today. Dr. Christian Guilleminault was cited by many presenters. Ballroom A was filled as Dr. Oliviero Bruni offered a heartfelt memorial, expressing the gratitude of an entire discipline of medicine to our inspiring and innovative leader for many years. RIP, CG. An overwhelming theme of many talks was the need to move from ‘one therapy for all’ thinking toward precision medicine, identifying phenotypes of patients and offering the therapy most likely to address their individual concern. The sophistication of diagnostic devices and software has made it possible to discern far more details about our patients’ sleep than was there at the beginning. AHI is no longer the dominating metric for diagnosis. Dr. Danny Eckert has led the way in breaking down the measurements

to label the pathology in different ways. This will lead to more successful therapy earlier after diagnosis than ever before. If the major problem is low arousal threshold, let’s treat that with medication; if it’s an anatomy issue, oral appliance or sur- Steve Carstensen, DDS gery might be first choice. Diplomate, American Board of Precision medicine combined with Dental Sleep Medicine technology advances will allow medical providers of all types to be part of identification and treatment decisions for patients. Informed, well-trained dentists will be taking increasingly important roles in management of sleep related breathing disorders. Panel after panel, symposium followed by another talk – there were physicians, dentists, PhDs, clinicians and professors, all working together to share their knowledge with their peers. I can’t imagine an attendee walking out of the Vancouver Convention Center without a spark in their eyes and excitement in their voice to get back to practice and help people get better. This is how a medical meeting should be run. This is my last issue of Dental Sleep Practice as Editor-in-Chief. For the past 5 ½ years, I hope you’ve seen in these pages inspiration, education, and the passing along of clinical wisdom, all so you can be a better doctor and improve the health of your community.

Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing questions about the special ADA Policy statement section which starts on page 14. The CE quiz can be submitted online at www.dentalsleeppractice.com or via mail. Sponsored by MedMark, LLC, and Seattle Sleep Education.

DentalSleepPractice.com

CONTENTS

Cover Story

Embrace Disruption – Rewards Come with Adding Technology by John Pasicznyk, DDS The effort is worth it!

2 CE CREDITS

Continuing Education/ Special Feature

Read what industry leaders say about sleeprelated breathing disorders and the ADA policy statement’s impact on your practice, Part Two.

An Ounce of Prevention: Avoiding Oral Appliance Therapy Related Side Effects by Jamison Spencer, DMD, MS

Defining Successful Therapy by W. Keith Thornton, DDS

Surgical Management of Sleep Related Breathing Disorders by Edward Zebovitz, DDS

Narrowing the Gap Between What is Known and What is Practiced

Product Study

The Oventus O2Vent® Optima Nylon Appliance by John Viviano, DDS, D.ABDSM How to address nearly every medical need.

66 2 DSP | Winter 2019

by Chelsea Erickson, DDS

We’re Not in This by Ourselves – Communicating with Other Medical Professionals by Ronald S. Prehn, ThM, DDS

After the Symptoms are Resolved by Mark Murphy, DDS, and Eddie Sall, DDS, MD

Legal Ledger

Telemedicine and the Provision of Dental Sleep Medicine by Jayme R. Matchinski, Esq. What can you do online?

CONTENTS

Publisher’s Perspective

Celebrating 15 Years of Growth and Learning by Lisa Moler, Founder/CEO, MedMark Media

Product Spotlight

SomnoDent Avant – New Appliance, New Mission Innovative design to meet clinical need.

Laser Focus

CO2 Laser Surgery Post-Operative Pain and Healing: A Partial Literature Review by Anna (Anya) Glazkova, PhD, and Peter Vitruk, PhD Why you can believe in this therapy.

Product Focus

A Perspective on Case Acceptance in DSM by Mark T. Murphy, DDS, D.ABDSM New thinking, better results.

Marketing

Growing a Dental Sleep Practice: Step 3 – Online Promotion by Marc Fowler Breaking through the noise to promote your service.

Product Spotlight

TMJ & Sleep Therapy Centre International

Expert guidance for TM Joint and sleep education.

Winter 2019

Product Spotlight

The SnoreHook Splint An easy, in-office solution.

Practice Management

Are You Ready for 2020? by Glennine Varga, AAS, RDA, CTA Moving forward means everyone is on board.

4 DSP | Winter 2019

Editor in Chief | Steve Carstensen, DDS stevec@medmarkmedia.com

Let Technology Help You Streamline Medical Billing

Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com

by Rose Nierman, CEO, Nierman Practice Management It’s getting easier to be paid.

Steve Bender, DDS Douglas L. Chenin, DDS Howard Hindin, DDS Ofer Jacobowitz, MD Christina LaJoie Steve Lamberg, DDS, DABDSM Dale Miles, DDS Amy Morgan Mayoor Patel, DDS, MS, RPSGT, D.ABDSM John Remmers, MD Rob Rogers, DMD Sarah Shoaf, DDS, MSD Bruce Templeton, DDS, MS Jason Tierney Glennine Varga, AAS, RDA, CTA

Product Spotlight

Great Lakes Now Offers the Medley Sleep Appliance The ultimate flexibility for appliance choice.

Case Study

Editorial Advisors

Rhinomanometry Measuring Nasal Flowrate to Improve TMJ Function by Steven Olmos, DDS, DABDSM A surprising connection.

Product Spotlight

BeamReaders

National Account Manager Celeste Scarfi-Tellez | celeste@medmarkmedia.com Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com

by Dr. Zubad Newaz Every professional doing their best.

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

Product Spotlight

Hybrid Practice Leads to Hybrid Therapies Team Focus

Publisher | Lisa Moler lmoler@medmarkmedia.com

by Joseph Zelk, DNP, FNP, BC, CBSM, DBSM Working together for patient success.

Seek and Sleep

DSP Fill It In

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

PUBLISHER’Sperspective

Celebrating 15 Years of Growth and Learning

s the publisher of Dental Sleep Practice, I have had so many opportunities to read, meet, and learn from “master teachers” — their wisdom comes from many fields, from dental KOLs to management gurus to technology and self-improvement. One of the ways that I keep their tenets in mind is through collecting meaningful quotes — one of my greatest passions. Quotes from Wayne Dyer, Jim Rohn, Zig Ziglar, Marianne Williamson, and Tony Robbins reflect where I’ve been and what I’ve achieved in my half century on this earth. Each insight, opinion, and perspective has served as an integral part of my own personal growth, as well as the growth of each of MedMark Media’s publications. In the coming year, MedMark Media celebrates its 15th birthday! It’s been a growth experience, not only for me, but also a time of growth, learning, and building relationships among our readers, authors, and advertisers.

Lisa Moler Founder/CEO, MedMark Media

6 DSP | Winter 2019

This issue of Dental Sleep Practice includes Part 2 of our ADA/CE special feature and continuation of the interpretation of its policy statement. Articles in this section include topics such as how to define successful SRBD therapy, goals for surgical management of SRBD, how to effectively follow-up with SRBD patients, and the importance of keeping up with the latest research and education on SRBD. (We are always honored to be a part of that process.) Dr. John Pasicznyk shares his passion for incorporating technology into his practice for a better patient experience and expanding his services mix. He explains, “Treating those with sleep apnea and airway issues has shown me how critical the dentist is in our patient’s health, and dental technology has helped create awareness, drive faster and more accurate diagnosis, and provide higher quality outcomes.” With these articles, we strive to help nurture the clinical and business sides of your practices to reduce your stress and increase your success. Fifteen years ago, MedMark Media’s home office was based here in my hometown of Scottsdale – my corporate headquarters was comprised of a make-shift office in my tiny second bedroom. My sole employee was a 17-year-old intern who found the job from a posting that one of my fellow publishing friends put up at one of the local colleges. I had a hopeful hunch that she would work out. Diving into contracts and paper-

work, we shared a computer and a dream of producing a publication that mattered in the dental industry. Within that first year, my Arizona market held the top ranking out of about 12 markets at the time. And, amazingly, 15 years later, my first employee, Adrienne Good, is still a valued member of the much larger MedMark Media team that now has grown to include departments for editorial, production, advertising, and digital media. I am fortunate to be a part of this beautiful “dental world,” and can honestly say that this industry, and the amazing people I’ve met within it, has literally saved my life. I found my niche, and for 15 years have been striving, along with my team, to help you find and cultivate your niches. We all continue to innovate and seek new ways to help our readers reach new personal and professional heights. Of course, as in any profession, there will be challenges, but we want to provide you with the tools to step back, take a deep breath, and think, “I got this.” Feel free to contact us to share your ideas and articles. Along the way, I have had so many conversations and learned that everyone has a unique way of looking at the world and overcoming obstacles. We start this 15th year with hope, appreciation, and the knowledge that every day is an opportunity for learning. Thank you for being a part of our journey. To your best success!

The Endo, Perio, Hard & Soft Tissue, Sleep & Snore Laser Er:YAG & Nd:YAG Combo

Airway Enhancement NightLase Treatment is a fast, non-invasive and friendly way of increasing the quality of a patient’s sleep. NightLase can decrease the amplitude of snoring through the use of gentle, Fotona proprietary Er:YAG laser light. No anesthesia is used in this treatment.

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To learn more about what the Lightwalker™ can do for your practice contact Fotona at (972) 598-9000 or marketing@fotona.com today.

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COVERstory

Embrace Disruption – Rewards by John Pasicznyk, DDS

“I

’ve made a huge mistake” are words you never want to think when starting a career in dentistry. Yet, that’s exactly where I found myself early on. By all accounts, life should have been great: I recently bought a growing fee for service practice just miles from my home, taking care of patients that appreciated the dentistry I was doing, and had a great team around me. Unfortunately, I was experiencing the exact opposite; I had no joy or excitement in my work and was struggling to go into the office every day. I couldn’t quite put my finger on why I felt the way I did – I simply was not happy living by the old dental adage of “drill, fill, and bill.” If this story sounds familiar to you, don’t worry. I’m living proof that it’s possible to revitalize your enthusiasm for dentistry and create a change in your practice. In just a few short years, I’ve transformed my practice from a typical restorative practice to a multi-disciplinary dental facility with an emphasis on sleep medicine. This shift in the practice didn’t happen overnight, and there was no magic bullet, but I am confident that without adding dental technology to the practice, I would not be where I am today.

One of the hardest aspects of dentistry is being a business owner. This is just as true for associate doctors as it is for the business owners themselves. Your actions, clinical abilities, and attitude toward dentistry directly influence your ability to make a living, no matter who signs your paycheck. And as business owners, now more than ever, we should be very concerned with the changes in dentistry. Stagnant or decreasing dental reimbursement rates, rapidly changing consumer attitudes and expectations, and unprecedented competition are all greatly contributing to a negative outlook within our profession. Looking back at the low point in my career, I can certainly say these stresses played into my discontent. But rather than accept these stresses in my life, I chose to fight against them by differentiating myself so I stood out from the pack, and then worked tirelessly to become even less dependent on dental insurance. I accomplished this with two major changes: first by incorporating CEREC and CBCT within the practice, which allowed me to provide a better patient experience. Secondly, I learned to leverage the technology in order to expand my services mix. Once I began

Dr. John Pasicznyk was born and raised in Aurora, Ohio outside of Cleveland. He attended undergrad at Butler University, majoring in chemistry and playing for the football team, and dental school at Indiana University School of Dentistry. After graduation, Dr. Pasicznyk worked for the Department of Veterans Affairs in Indianapolis. As a member of the prestigious CERECdoctors.com Mentor Group and a beta tester for Dentsply Sirona, Dr. Pasicznyk travels the world training dentists on the very same technology that he uses in his office. He is a volunteer at the Trinity Free Clinic in Carmel and a member of the American Dental Association, Indiana Dental Association, Indianapolis District Dental Society and the Academy of General Dentists. He also continues to be an active member of the Delta Sigma Delta dental fraternity. Dr. Pasicznyk and his wife, Meghan, live in the Meridian Kessler neighborhood with their son, Roman, and German Shorthaired Pointer, Greta. Dr. Pasicznyk captures a digital scan with CEREC as part of his patient’s treatment plan.

8 DSP | Winter 2019

COVERstory Come with

Adding Technology

DentalSleepPractice.com

COVERstory

“

The practice has become known for its comprehensive use of technology.

making this intentional change within the practice, I found myself striving to provide more advanced dentistry. I was no longer content to prep crowns all day; I now wanted to make an emotional and life changing impact on my patients. There are a number of very important questions we ask before making a major purchase like a CEREC system or cone beam CT. Questions like: how much can I save on my lab bill? How many CTs can I bill out in a month? How much more can I charge for the convenience of this technology? But I would challenge anyone prepared to make this investment to stop thinking about these easy questions. Rather, spend the time to properly prepare yourself and your team for the rapid change you are going to see in your practice as you add this technology. Find mentors that can support you in your journey, identify areas of growth you would like to see within the practice, and determine what procedures you can add to the practice. I always tried to look at the bigger picture, and, rather than focusing on only the technical aspects of the technology, I spent a great deal of time integrating it with my practice’s mission and vision. This took time and effort, but it didn’t go unnoticed by patients and the practice has become known for its comprehensive use of technology within every facet of patient care. In the midst of learning about all the technical capabilities of the equipment, I met some incredible mentors and friends that have shaped who I am. These important people pushed me (and still do to this day) to do more for my patients, to learn new things, and to put myself in uncomfortable situations.

There seems to be a natural tendency to do more of the things that lie within our small comfort zone, which seriously limits our ability to grow. Dentists are creatures of habit, fearful of the effects of a disruption. The real shame of it is, without disruption, there is no growth. By being fearful of the disruption, we limit our ability to grow which makes us more fearful to disrupt things, and on and on it goes. There is no doubt adding cone beam (CBCT) and CEREC created a disruption to the practice. New equipment brought new processes, new materials, new terminology, and new scheduling behaviors, just to name a few. Once I became comfortable with both the technical and implementation aspects of technology, it was time to expand services within the practice. I was very quick to utilize CBCT and CEREC for guided implant surgery and enhanced diagnosis of dental issues. The practice grew around these services. The net progression in the practice was treating sleep apnea and airway issues. Talk about a disruption! Treating airway opens the door to all kinds of things: a new health history, new conversations with patients, new billing procedures, new examination and note-taking protocols, and the list goes on. Luckily, my team was fully on board with this disruption. I discovered the excitement I brought to work every day made this newness feel less scary. As my team embraced what I was asking, they began to see successful outcomes and that made them even bigger believers. Unfortunately, I found myself struggling to describe my concern with patient’s breathing and sleep issues. I talked too much,

“

Orthophos SL 3D (left) and segmented airway in SICAT Air captured by the Orthophos SL (right).

10 DSP | Winter 2019

COVERstory

CEREC Primescan digital impressions capture every detail of the patient’s dentition, which can help enable more treatment modalities, sleep appliances for OSA.

cause, truth be told, dental sleep medicine is generally technology agnostic. However, buying CEREC and cone beam technology and learning to fully utilize the capabilities introduced me to very influential people in my life. I admired and wanted to be like them, so I took their teaching and urging to continue to do more to heart. Without them, I would never have been so motivated to grow my clinical skillset, and most likely would never have learned what an impact I could make by treating airway issues in the practice. Like so many others, I am incredibly passionate about treating airway in the practice, and also like my peers, I learned absolutely nothing about it during formal dental training. Obstructive sleep apnea is, by some accounts, an epidemic in our country, and dentists have the capability and know-how to provide help. Yet, there are so many that are hesitant to provide therapy to their patients because of the disruption it will cause. If only they could see the excitement this particular disruption will bring to their practice! To say that dental technology changed my practice is a vast understatement. Looking at where I am today, I can confidently say my career has been shaped by digital technology. Each step of the journey, I learned more and more about how to help my patients in a more impactful way. The newest frontier for me has been the world of airway and dental sleep medicine, and I couldn’t be more excited for the future. Treating those with sleep apnea and airway issues has shown me how critical the dentist is in our patient’s health, and dental technology has helped create awareness, drive faster and more accurate diagnosis, and provide higher quality outcomes. My desire is for more dentists to impact their patients in the same fashion, even if it means a few disruptions along the way.

“

The excitement I brought to work every day made the newness feel less scary.

“

drew pictures, or showed them a diagram of a tongue falling to the back of the throat. None of these methods were very successful. Luckily, technology came to the rescue. I am one of a growing number that can very confidently say: CBCT helped me grow my sleep apnea practice. SICAT Air software and its unique ability to segment and give a volumetric analysis of the patient’s airway was a gamechanger. Just like that, I could have a 3-dimensional representation of someone’s air passage, just by using our routine cone beam scan that was already in the patient’s chart. Starting the airway conversation became much easier and a more natural part of the patient experience. And before I get any emails or calls, I am absolutely clear with my patients that their airway analysis in no way, shape or form constitutes a diagnosis of obstructive sleep apnea. However, this analysis, along with a thorough radiographic examination of the cone beam volume, is a conversation starter. For me, in the technologically driven practice, this made a significant difference to sleep and breathing conversations. From there, things really took off. Using the full suite of technology at my disposal, I now see more efficient and effective results with my oral appliance therapy. Utilizing MATRx Plus theragnostic testing provides us an objective indication whether the patient will respond to oral appliance therapy or not by measuring the effects of therapy prior to appliance fabrication. It also provides the ideal initial treatment position, which limits TMD-related complaints, decreases adjustment visits, and increases the patient’s confidence in the type of care we provide. Once we see the patient is a predicted responder, CEREC Primescan digital impressions capture every detail of the patient’s dentition, which leads to a more precise fitting appliance than I’ve delivered in the past. There are minimal adjustments needed to comfortably seat the appliance, and a digital record gives us a lifelong model of the patient’s mouth prior to treatment. Digital technology has made the records and appliance steps of treatment repetitive, precise, and more effective than before. We are consistently finding less titration is needed with our appliances since moving to a fully digital workflow, minimizing what was a nuisance to both the practice and the patient. Without this full suite of digital technology, I would still treat sleep apnea, but for fewer patients and with more time and effort invested in each case. It’s always interesting to explain how technology influenced my journey into sleep, be-

DentalSleepPractice.com

PRODUCTspotlight

SomnoDent Avant – New Appliance, New Mission

omnoMed 2.0. It’s a concept the company has been actualizing since November 2018, when Neil Verdal-Austin, the newly appointed CEO of SomnoMed stepped into his role. Verdal-Austin launched a renewed mission for the company, one of being “treatment-focused and technology driven”, and our entire industry is starting to see it’s turning out to be more than just another catchphrase. Each member of SomnoMed’s Executive team has adopted a personal approach to strengthening relationships with sleep dentists across the country, listening to their feedback, and maintaining open lines of communication. Additionally, a focus on “best in class” products and the promotion of oral appliance therapy for the treatment of obstructive sleep apnea remains the center of the company’s focus. Not just listening to customers – acting on what SomnoMed heard has decreased average case turnaround time to only 12 calendar days and shown a decrease in returns by 48%. On the heels of this success, the company recently launched their latest product, the SomnoDent Avant. The SomnoDent Avant is SomnoMed’s smallest, strongest and first milled oral device with a soft liner for fit that

12 DSP | Winter 2019

is comfortable for patients. The company has partnered with key opinion leaders including Dr. David Schwartz, Dr. Kent Smith, Dr. Steve Carstensen and Dr. Tarun Agarwal to share their personal experiences in fitting patients with the SomnoDent Avant with audiences across the country. According to Dr. Smith, “the SomnoDent Avant is a game-changer!” The comfort of the device has been positively received by patients based on a study conducted by Professor Marc Braem at the Antwerp University Hospital wherein 100% of patients rated Avant as either comfortable or very comfortable. The results of the study also showed that after 42 days, treatment with SomnoDent Avant resulted in a statistically significant decrease in AHI, with an even larger improvement in AHI-supine for back sleepers. The strap-based design acts like elastics, pulling the top and bottom jaw together and keeping the mouth closed while maintaining forward posture in all sleep positions. The SomnoDent Avant can be ordered via SomnoMed’s online portal located at somaccount.com. The convenience of ordering online, utilizing iOS scans and CADCAM manufacturing, creates a completely digital workflow so dentists save chair time and enjoy shorter turn-around time from the manufacturer. “More and more dentists are starting to see [intraoral scanning] as viable – it’s efficient; it’s time saving; it’s accurate. And for us, it’s the future,” Verdal-Austin commented. SomnoMed is forging new territory with this new digital, fully-milled, device with a soft liner, the first, but not the last. Doctors are sharing their thoughts, and SomnoMed is listening. Welcome to SomnoMed 2.0.

SomnoDent Avant

™

SomnoMed’s smallest, slimmest, strongest and first milled oral device with a soft liner for the treatment of mild to moderate obstructive sleep apnea (OSA).

“The SomnoDent Avant is a game-changer!” - Kent Smith, DDS

We are proud to introduce you to our new SomnoDent Avant. SomnoDent Avant is digitally designed for dentists who want a slim, durable device with a quality fit and finish. Our CAD-CAM manufacturing system ensures a precise and consistent fit.The SomnoDent Avant has an innovative titration system and our proprietary BFlex soft liner for patient comfort, all from a company that values service and quality for our dentists and their patients. With both an easy “first time” fit and fast turnaround time of 14 calendar days, your patients will value wearing one of the slimmest and most comfortable oral devices available. • Durable SomnoDent Avant Advancement Straps provide simple calibration in 1mm increments • An initial set of 10 straps provided with your case with additional sizes available in small, medium, large (10 per set) to cover every patients complete advancement range • Completely digital process produces a precisely fit device with exceptional strength • Backed by SomnoMed’s dependable 3-year warranty Try the new SomnoDent Avant. Call us at 888-447-6673, option 4. somnomed.com/avant Early Results are In... • At follow-up, 100% of patients reported that SomnoDent Avant is comfortable* • 96% of patients report that their quality of sleep improved* Quality of Sleep 81%

Very Comfortable

19%

50%

42%

Good

Great

Comfortable

SomnoDent Avant Comfort

4% 4% Acceptable Poor

*SomnoDent Avant Study, Prof. Marc Braem, BE-UZA, Antwerp University Hospital, August 2018.

SomnoDent Avant is the registered Trademark of SomnoMed Ltd.

SPECIALfeature

An Ounce of Prevention: Avoiding Oral Appliance Therapy Related Side Effects by Jamison Spencer, DMD, MS

ADA

ith serious systemic health consequences being clearly linked with not treating SRBD, any potential dental side effects related to treatment of such disorders are a small price to pay. After all, tooth movement and occlusal changes rarely result in heart attack, stroke or death. Still, the caring dentist wants to minimize problems for their patients.

14 DSP | Winter 2019

The keys to avoiding these troubles are: 1. Recognizing in advance if the patient may be at greater risk for any specific side effects. 2. Proper appliance choice and fabrication. 3. Utilization of methods to help the patient re-align their habitual occlusion and regularly check for tooth movement and bite changes. 4. Proper follow-up. To be clear, the most common side effects related to oral appliance therapy are transient and typically of little concern to the patient. Localized discomfort in a single tooth or a few teeth, increased salivation, disrupted sleep as they get used to wearing the appliance, localized muscle soreness and occasionally discomfort in one or both temporomandibular joints are relatively common and tend to improve quickly without any modification to the appliance or intervention. Patients should be educated that such temporary effects are to be expected and are part of the normal accommodation process.

1. Recognizing in advance what side effects for which the patient may be at greater risk. I strongly support the statement in the ADA’s policy directing dentists to continually update their knowledge and training of dental sleep medicine with continuing education.

This knowledge and training MUST include understanding temporomandibular disorders and principles of muscle pain. While a complete list of all potential OAT risk factors is beyond the scope of this article, here are several conditions I believe are important. Periodontal disease: Patients with periodontal disease are at higher risk of tooth movement or loss of teeth. The dentist should decide if OAT is the best option or if CPAP, in combination with comprehensive periodontal therapy, might be necessary until acute conditions are managed. Internal Derangements: Reducing and non-reducing disc displacements and degenerative arthritis may make a patient more likely to develop occlusal changes and/or discomfort in one or both jaw joints. Reducing Disc Displacement (RDD): The articular disc is off the condyle when the teeth are together and on top of it when the mandible is forward, such as with OAT. Until the tissues adapt, the patient feels a ‘pop’ when the disc moves off and on the condyle. We discuss this carefully with every patient, including the rare occurrence of a permanently repositioned disc which can create a posterior open bite. Non-Reducing Disc Displacement (NRDD): When the disc is chronically displaced or dislocated anterior to the head of the condyle in all mandibular movements. Usually a history reveals popping that ‘went away.’ As with RDD, oral appliance therapy is not contraindicated. Patients need to be educated on what is likely going on and that OAT may exacerbate a condition that has not bothered them in a long time, including a return of the ‘clicking.’ Unlike RDD, the most likely side effect with NRDD is joint pain and retrodiscitis (which may result in a transient posterior open bite, but due to swelling related to inflammation, not changes to disc position). These patients are treated and encouraged in

SPECIALfeature the same way as any minor injury with inflammation.

2. Proper appliance choice and fabrication.

While there are many considerations in choosing the best appliance design for overall efficacy, patient comfort, and compliance, it has not been shown that specific appliance designs are more or less likely to result in side effects such as pain, tooth movement or bite changes. Patients with tooth wear may have a reduction of their bruxism with treatment of their SRBD. I choose an appliance that will allow the patient to move their mandible in the same way that they had to in order to create the wear. They may continue to brux and be at higher risk of damaging or prematurely wearing out appliances. This should be explained so that the patient knows that these are side effects of their bruxism rather than the appliance. A common error is not “wrapping” the distal of the most posterior mandibular teeth. Whenever possible the lab should wrap the distal, which will make it less likely that the other teeth in the arch will be pulled forward, resulting in open contacts.

3. Utilization of methods to help the patient re-align their habitual occlusion and regularly check for tooth movement and bite changes.

4. Proper Follow-up

Regular visits confirm the therapy is still effective and allow the dentist to recognize and

Conclusion

Even though many medical problems associated with not treating OSA are far more serious, the patient must understand the potential side effects of OAT and their role in avoiding them, their responsibility in keeping follow-up appointments, and decide to move forward with therapy. The dentist must be able to recognize and manage common side effects or refer to those who have the necessary expertise.

Educational purpose:

The ADA’s Policy Statement on the Role of Dentists on treating Sleep Related Breathing disorders arguably triggers more changes in dentist behavior as it relates to the health of their patient than any other policy statement published by the ADA. Dentists who understand the implications found within the statement will impact community health beyond any expectations they might have made during professional training or practice. The purpose of these essays are to bring together the opinions of the nation’s leading experts so every practicing dentist can recognize areas where mastery exists and where further study is necessary. At the end of this reading, the participant will be able to 1. Discuss with their team and peers the implications of the policy statement for their practice 2. Lead their teams to develop communication skills so the changes can be introduced to patient communications 3. Have confidence their practice is working towards the highest ideals of collaborative medical/dental services.

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.

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It has become common to provide some sort of “morning occlusal guide” to help the patient recover their normal bite. I strongly encourage you to provide every patient with such a device and verify they understand how and why to use it. We explain to the patient that if they notice their previously tight contacts are now easier to floss or they now seem to be hitting harder on the front teeth, they are to contact us immediately. When we catch things early it is much easier to deal with the issues. In my experience, patients who develop tooth movement or bite changes are usually either not doing what you asked them to do or they are doing it wrong. This is why regular follow-up is vital.

manage changes, many of which are unnoticed by the patient. With oversight, it is much less likely that a patient will develop significant dental side effects.

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Defining Successful Therapy by W. Keith Thornton, DDS

discussion of the ADA Policy Statement and recommendations for long term treatment (disease management) must be predicated on the definition of sleep related breathing disorders (SRBD), the various treatments, the severity of the condition, and the understanding of the patient’s desires and objectives. Only then can a cogent algorithm for management be proposed to apply precision medicine to the individual. SRBD

ADA

The term describes the behavior of the passive pharynx during sleep: a continuum from snoring, flow limitation, Upper Airway Resistance Syndrome (UARS), to obstructive sleep apnea. The continuum is called pharyngeal instability. Only when it reaches the end stage of significant under-breathing and oxygen desaturation (hypopnea) or cessation of breathing (apnea) does it rise to the level of a medical disease called obstructive sleep apnea (OSA) and defined by the ApneaHypopnea Index (AHI). Most people with SRBD do not have OSA. All breathing is controlled by a central, chemical controlled, feedback loop (Fig.1). Dr. Magdne Younes in 1989 found that both the pharynx and ventilation were unstable (loop gain) instead of just the pharynx. This understanding has been applied more recently to SRBD and OSA (White

Figure 1

16 DSP | Winter 2019

Figure 2

2005). A better term for SRBD should be Sleep Pharyngeal-Ventilatory Instability (SPVI). It is interesting that the ADA Policy states that SRBD is “caused by anatomical airway collapse and respiratory control mechanism.” Thus, treatment efficacy must include titrating the mandibular position, affecting pharyngeal stability, but also by addressing loop gain. Ventilatory instability can be improved by eliminating mouth breathing, taping the lips or using a mouth shield with an oral appliance. Even daytime breathing exercises can improve loop gain. The dentist is in the unique position of being able to manage all levels of SRBD including severe OSA, complex OSA, and even some central sleep apnea (CSA), utilizing a systems approach. Most physicians are aware that CPAP therapy is problematic due to compliance. Studies are showing that CPAP does not improve cardiovascular outcomes. Approximately 75% of patients fail a minimum CPAP use of 4 hours per night 5 days per week. It would seem logical that oral appliance therapy would be tried first. A barrier to this approach is the lack of standard of care in dentistry, including screening, appliance selection, titration, and follow up. The complaint of sleep physicians is that most devices are not predictable, fail to reach the success criteria (an AHI<10, a reduction by at least 50% and the elimination of symptoms), and are very expensive. A great advantage of CPAP is that a trial is always done before a purchase. Studies show that the only consistently successful appliances are titrated objectively, while even the best fail without titration. A key trait is the ease of patient titration.

SPECIALfeature Screening and Monitoring

Whether a patient with suspected SRBD is a patient of record, referred for treatment, or has failed PAP, standardized objective and subjective screening should be done prior to any therapy to determine need for referral or as a baseline for titration, monitoring and clinical decisions. Examples of subjective tests are Epworth Sleepiness Scale and Thornton Snoring Scale. Consumer sleep technologies, such as smartphone apps, may also be helpful. Objective tests include oximetry, cardiopulmonary coupling, and even home sleep apnea tests (HST). Tests should be simple, inexpensive, and reliable. With a failed CPAP patient or with a patient who prefers an oral appliance, the goal of titration would be to achieve a high negative predictive level that would assure the patient doesn’t have OSA while wearing the device. Pulse oximetry meets these criteria well and has been used by the author for 26 years. If time below 90% oxygen saturation is less than 1% of the night, there is less than a 2% chance of having OSA, particularly with elimination of the patient’s symptoms (Series 1993). Traditional oximetry and HST measure only pharyngeal instability and only for OSA, not all SRBD. However, high-resolution pulse oximetry appears to be able to measure both pharyngeal and ventilatory instability and can detect everything from flow limitation to OSA, and even CSA. It also classifies the severity of the SRBD including cycling time and depth (Figs. 1-3). The analysis includes all of the traditional parameters, providing doctors the greatest amount of information to make clinical decisions.

Oral Appliance Therapy

Standard of Care in the Dental Office

Once the decision has been made to provide OAT, both a before and after objective

screening to measure the efficacy of the appliance for OSA is required. A sleep physician is almost always involved with pre-treatment testing and provides baseline data that the dentist can use during therapy to gauge success of the OA. The dentist should be welltrained on any testing device that is employed and collaborate with the patient’s physician on how the data is interpreted. Increasingly, trial MADs are being used to evaluate patient response even prior to formal sleep testing; the dentist must be well trained and alert for subtle signs of ongoing problems. For example, cessation of snoring should not be assumed to be the end point of therapy. Yearly appointments with objective monitoring are mandatory. Devices may need to be re-titrated due to changes in weight, medical conditions, or medications. Critical to success is both the efficacy and effectiveness of the device – does it work and are they using it. If not efficacious, another appliance should be tried or other treatment options discussed. Communicating and collaborating with the patient’s physician(s) is an integral part of the process.

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.

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The greatest weakness in treating SRBD by oral appliances is the inconsistency of the outcomes with the various appliances. With over 120 cleared appliances, there is a need to determine which ones have the capability of managing all levels of OSA including severe and then titrate them appropriately. The best source for evidence comes from the 2015 AASM/AADSM Guidelines on Oral Appliance Therapy – every dentist should study those guidelines and choose devices that demonstrate the best outcomes on the 40 RCT that were included.

Figure 3

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Surgical Management of Sleep Related Breathing Disorders by Edward Zebovitz, DDS

ADA

irway surgery is a viable option when alternative treatments have been deemed intolerable, ineffective, or if the patient desires correction instead of management of the disease. Dentists are uniquely positioned with a varied skill set to address SRDB in the growing child to develop a normal airway and to manage adults with anatomic airflow restriction. Indications for surgical management include: targeting subjective and objective signs and symptoms, correcting underlying dentofacial deformities, addressing anatomic airflow restrictions, and redirecting airway-related compensations, such as forward head posture and jaw protrusion.

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Addressing the airway restriction in the OSA patient requires careful diagnosis by means of direct clinical visualization of airway anatomy while awake or asleep (by drug induced sleep endoscopy) and imaging: CT, CBCT, MRI static and dynamic. Airway restriction can be the results of anatomic issues in any part of the upper airway and oral cavity â&#x20AC;&#x201C; the craniofacial respiratory complex. Airflow restrictions can be located anywhere between the nares and the larynx â&#x20AC;&#x201C; including structures bounded by bone such as the piriform aperture and nasal airway, and soft-tissue-defined areas like the naso-, velo-, and oropharynx. If the palate is elon-

gated or the lymphoid tissues (adenoids and tonsils) are hypertrophied, the airway may be narrowed. Oral cavity airflow restrictions can be related to constriction in available 3D volume for the tongue and the subsequent effects on the oropharynx. The size of the tongue is variable; while it can accommodate the surrounding structures, the available space for the tongue can be restricted by deformity of anatomic oral structures (e.g. palatal or lingual tori, ankyloglossia), narrow maxillary and/or mandibular arches, and deficiencies in the antero-posterior position of the mandible, maxilla, or combination of both. Intranasal or oropharyngeal soft tissue airflow restrictions are typically referred to our otolaryngologist colleagues to address. Their typical procedures include: adenoidectomy, tonsillectomy and, less often, uvulopalatopharyngoplasty (UPPP). Other options include tongue base or epiglottal surgery, septoplasty, inferior nasal turbinoplasty, nasal valve stenting and palate-stiffening procedures. Addressing the specific areas of oral airflow restriction related to width or transverse deficiencies can be addressed by techniques to expand the arches: there are three primary approaches for the adult SDB patient. First, expansion orthodontic mechanics by means

SPECIALfeature decisions are based on careful, detailed and educationally focused pre-operative consultations with the patient and the oral and maxillofacial surgeon. Additional decision making is influenced by idealizing the occlusion and determining if maxillary repositioning surgery is required to bring the palate forward, away from the posterior pharyngeal wall. If indicated, intranasal issues can be addressed simultaneously (e.g. septoplasty, turbinate reduction or piriform rim widening). This is advantageous in reducing the number of surgeries and recover- The goals are a ies. Maxillomandibular advancement (MMA) surgery differs from traditional more forward two-jaw orthognathic surgery in mag- tongue posture, nitude and focus, with MMA surgery primarily focused on addressing airway less restricted nasal related issues with a goal typically in airflow and increased excess of 10 mm of advancement. Additional adjunctive airway proce- oropharyngeal size. dures are available and can be utilized in isolation and in combination with MMA, genial tubercle, or hyoid suspension procedures. Precise assessment of structures, possible with CBCT, MRI and clinical measurements, allows the airway surgeon to maximize increases in posterior pharyngeal space. In summary, surgical options can be performed with predictable results and should be considered for patients with anatomic issues who are younger, or any who wish to attempt correction of their airway and/or have failed conservative therapies to address OSA. Dentists and surgeons work together to help patients avoid the medical implications of untreated sleep related breathing disorders.

Edward Zebovitz, DDS, an accomplished oral surgeon by day, and generous humanitarian, dedicated husband, father and international citizen after hours. Making the most of his gifts and talents, Dr. Zebovitz is as comfortable practicing in his state-of-the-art office as he is in rural primitive facilities, serving the needy across the globe, and across the street. Since 2006, Dr. Zebovitz has served as Chief of Oral and Maxillofacial Surgery at Anne Arundel Medical Center in Annapolis, Maryland. He is certified by the American Board of Oral and Maxillofacial Surgery (ABOMS) and is a Fellow of the American Association of Oral and Maxillofacial Surgeons (AAOMS). Dr. Zebovitz’ thriving practice, established in 2000, is located in Bowie, Maryland. He is quick to share his success with his loyal, gentle and patient centered staff.

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of traditional orthodontics or clear aligners. The magnitude of expansion is 1-5mm and limited by maintaining the roots within the alveolar housing. When the roots are close to the buccal or facial cortical plate, root dehiscence and gingival recession are potential complications. The second option, Surgical Facilitated Orthodontics (SFOT) or Periodontally Accelerated Osteogenic Orthodontics (PAOO), is ideal for expansion requirements of 5-8 mm. These involve surgical exposure of the alveolar process and cortical bone scoring of the alveolus, outlining the roots on buccal/facial or palatal/lingual aspect, or both, depending on the proposed vector of tooth movement desired, followed by augmentation with allogenic bone graft material and meticulous soft tissue closure. Early and forceful application of well controlled force vectors is required. A 12-week window of opportunity exists, labeled “regionally accelerated phenomena” (RAP). This procedure also allows for simultaneous connective tissue grafting for root coverage and addressing mucogingival issues. The 3rd option, micro-implant rapid maxillary expansion (MARPE), is indicated for expansion requirements in excess of 8mm and in cases with intact periodontal support. This approach utilizes 1.7mm diameter implants placed to engage palatal bone on both sides of the suture. Additional procedures include surgically assisted rapid palatal expansion (SARPE) which add palatal osteotomy, lateral maxillary wall osteotomies and pterygoid plate release to allow more 3D expansion of the maxilla. The goal and results of these procedures allow for a more forward and relaxed tongue posture, less restricted nasal airflow and increased oropharyngeal size. Surgical management of antero-posterior deficiencies are focused on anterior repositioning of the posterior nasal spine, which positions the velum, and the genial tubercle, which directly applies tension on the genioglossus muscle. This tension results in antero-inferiorly positioning of the hyoid bone and advancement of the tongue base, which increases the posterior pharyngeal space in both antero-posterior and transverse dimensions – a true 3-dimensional enlargement. Decisions of the magnitude of genial tubercle advancement is based upon cephalometric and clinical evaluations to idealize facial proportions and maximize airflow. These

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Narrowing the Gap Between What is Known and What is Practiced by Chelsea Erickson, DDS

ADA

leep is such an essential part of health that humans spend a third of our lives doing it. 1 in every 5 Americans have Sleep Apnea (one of the most common sleep disorders) and nearly 40% of Americans suffer from some type of sleep disorder in their lives. As vital as sleep is to our overall health and wellbeing, its an area of health, that has been vastly overlooked for centuries in Western Medicine. A survey in 2002 of 500 medical doctors showed that none of them felt they had an excellent understanding of sleep and 90% of them rated their knowledge as fair to poor. In 2011 a nationwide survey done by Goh found that medical students are getting about 3 hours of sleep education in their curriculum. In comparison, they receive about 2 hours on dentistry and oral health. Sleep medicine wasnâ&#x20AC;&#x2122;t recognized as a specialty in medicine until 2003 and itâ&#x20AC;&#x2122;s still not recognized in dentistry. This demonstrates that we know very little about such an important aspect of every day life.

20 DSP | Winter 2019

SPECIALfeature As our knowledge and understanding of sleep has grown over the last 20 years so has the field of sleep and dental sleep medicine. We as dentists have distinct advantages when it comes to helping people who suffer from these disorders. Many of the symptoms of SDB either originate or manifest in the oral cavity. Not only are we highly trained to recognize poor oral health patterns as a part of disease, but we also can relate it to skeletal issues that many other professionals cannot identify. Few, if any other medical providers can make these assessments and correlations. This knowledge makes us a vital part of a team of providers necessary to comprehensively treat a patient who suffers from airway related sleep issues. Once they are properly diagnosed, dentistry may be called upon again to help with treatment. We are fortunate in dentistry that even though many of us practice by ourselves, we are still very much a collaborative community. We have study clubs, private and public education institutes, large group organized learning, and small group learning. We have blogs, Facebook pages and Instagram feeds. We can do week long focus courses or we can sign up for weeknight meetings. We have an abundance of information sharing but what we truly need as a dental community is more providers who are seeking out this information. When we focus on sleep as a part of overall health and comprehensive care, we all win. We are healthier, happier and safer in a community that is well rested. I personally feel that we have a double standard when it comes to medicine and our desired role. We want to be involved and regarded well in the medical community as a valuable re-

A continued interest and commitment to keeping up with current research and education is essential. source, but we also want nothing to do with the current medical structure of patient care. From billing and coding to the time we get to spend with our patients, we have tried to insulate ourselves from the main stream medicine world. Sleep and airway form a large bridge between medicine and dentistry and the overall health of our patients, and dentists are the gatekeeper. It is an important role which is vital to the health of our community. We are still early in our learning and understanding of sleep and treatment for sleep disorders. We are one of the primary providers of therapy to deal with the consequences of airway issues whether it be a MAD, orthodontics, or another type of therapy that address the airway directly. Because of the incredible growth of sleep knowledge and its importance to our patients and their care we must continue to learn from the growing research. It simply isnâ&#x20AC;&#x2122;t enough to take a week long course or even to become a Diplomate of the ABDSM. It isnâ&#x20AC;&#x2122;t enough to rely on the same appliances, approaches and research day after day. These are great accomplishments but a continued interest and commitment to keeping up with current research and education is essential. Dental sleep medicine is rewarding and completely life changing for both the provider and the patient and we owe it to ourselves, our profession and our patients to provide the best possible care with the most current standards.

Drs. Johnathan Parker and Chelsea Erickson

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Chelsea Erickson, DDS, is a North Dakota native and attended the University of North Dakota and graduated with Bachelor of Science in Chemistry in 2006. She then attended Creighton University in Nebraska where she graduated with her degree as a Doctor of Dental Surgery in 2010. She practices full time in East Grand Forks, MN. She has a passion for continuing education and travels often to learn the most update information especially regarding comprehensive care including airway, TMD and sleep. She is a member of 5 study clubs, is a visiting faculty member at the Pankey Institute in Key Biscayne, Florida and loves to help educate as well.

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We’re Not in This by Ourselves – Communicating with Other Medical Professionals by Ronald S. Prehn, ThM, DDS

xcellent care is separated from standard care by the quality of communication between providers. The dentist treating SRBD with excellence does more than is required by policy and law. The ADA policy statement addresses communication to both the patient’s referring physician and to other healthcare providers. The content of this communication concerns treatment progress and recommended follow-up treatment recommendations.

ADA

The recommended follow-up reports are to all the other members of the sleep treatment team. After the history and examination of a patient identified as having risk factors for a sleep related sleep breathing disorder, a referral to another healthcare provider may be indicated as either monotherapy (such as to an ENT for tonsillectomy) or adjunct ther-

22 DSP | Winter 2019

apy in combination with oral appliance therapy (myofunctional therapy or weight loss). There are many professionals with therapy expertise that can help resolve SRBD – and all deserve complete communication. The referring provider could be a PCP, ARNP, specialist physician or a board-certified sleep physician. The foundation of all communication lies within the diagnosis by the physician. During the process of a diagnosis, the physician considers the history and examination, the objective findings (testing), and the subjective symptoms (patient’s complaint). The sleep dentist should determine and record similar subjective symptoms as did the physician. If there are discrepancies in the subjective symptoms, then communication with the physician is essential to determine the patient’s chief complaint. The objective findings of the testing done by the

SPECIALfeature Another example would be if the subjective symptoms were resolved (patient is happy with sleep), but the objective testing indicates too much time spent (>1% of the night) under 90% blood oxygen. A referral back to the sleep physician to determine further treatment would be essential to success. In both of these cases, one would be looking for, as one choice, combination therapy to achieve therapeutic goals. Combination therapy has great communication as its foundation. There are many combinations to be considered; the most common is to use an oral appliance concurrently with PAP therapy. The physician would be prescribing PAP therapy and you as the treating Good communication sleep dentist would be managing oral is what is best for appliance therapy at the same time. A dentist cannot treat sleep related the patient and breathing disorders without a foundation of good communication with a phy- builds professional sician. Beyond that, some challenging satisfaction in all cases can only be successfully treated with close, frequent exchange of infor- providers. mation between providers. Reinforcement from everyone on the health care team may be essential to help the patient remain in oral appliance therapy as either monotherapy or in combination therapy. Good communication is what is best for the patient and builds professional satisfaction in all providers. It is also what will help to keep a collaborative relationship between our two professions…Medicine and Dentistry.

Ronald S. Prehn, ThM, DDS, is a third generation dentist who focuses his practice on complex medical management of Facial Pain conditions (TMD and Headache) and Sleep Disordered Breathing. He received his degree at Marquette School of Dentistry in 1981 and post graduate education at the Parker Mahan Facial Pain Center at the University of Florida and the LD Pankey Institute in the years to follow. He is a Board-Certified Diplomat of both the American Board of Orofacial Pain and American Board of Dental Sleep Medicine, of which he is president-elect. While being an adjunct professor at the University of Texas Dental School in Houston, he is published in several journals on the subject of combination therapy for the treatment of obstructive sleep apnea. He is a sought-after speaker on this subject at the national level. He currently limits his practice to management of complex sleep breathing disorders at the Koala Sleep Center in Wausau, Wisconsin while enjoying with his wife, Linda, the outdoor life style and people of North Central Wisconsin. He can be contacted at rprehn@tmjtexas.com.

DentalSleepPractice.com

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physician should be well understood by the sleep dentist. The diagnosis is the foundation of all medical judgments for each patient. Therefore, the clarity of communication at this level is critical to making good treatment decisions. After diagnosis by the physician, the essential communication begins when we inform them the patient has been examined and a treatment plan has been recommended. It is critical to keep the physician informed about the patient’s treatment decisions. Did the patient accept treatment? Has therapy been initiated, delayed, or rejected? Send a letter with your clinical notes, including your intention to have the patient return to the physician for final determination of the resolution of the sleep related breathing disorder. The depth of communication with the diagnosing provider and others on the health care team depends on the role each has in the diagnosis and treatment. During the titration phase of Oral Appliance Therapy, the effectiveness of the oral appliance in stabilizing the airway is being determined by subjective symptoms (e.g. written questionnaires and verbal inquiry) and objective testing (e.g. wrist pulse oximetry). Once your therapeutic goals have been reached, the patient is to return to the physician for confirmation of efficacy of the oral appliance – resolution of the sleep related breathing disorder. At this point communication should include your objective and subjective records of the appliance titration, as well as your protocol for long term monitoring of the oral appliance therapy. State clearly in your cover letter that you feel the patient is ready for therapy confirmation testing. Yearly communication and update of your patient’s condition should be sent to the patient’s providers. If you are unable to meet therapeutic goals with the oral appliance, enhanced communication to the boarded sleep physician becomes essential in order to help resolve the patient’s sleep related breathing disorder. For example, if you are able to reach objective goals with your oral appliance (blood oxygen levels above 90% more than 99% of the night and low heart rate variability), but unable to resolve subjective symptoms (e.g. fatigue), then a referral back to the sleep physician would be essential for additional medical workup.

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After the Symptoms are Resolved by Mark Murphy, DDS, and Eddie Sall, DDS, MD

ADA

hen we would embark on a trip, my kids used to wonder, and my grandchildren still ask, “are we there yet”? Honestly, sometimes I felt the same way. As you arrive at the gates of Disney or the hotel/resort you chose, there is a sense of relief, celebration and the satisfaction that you have safely completed the mission. So, too it is with treating obstructive sleep apnea for our patients. Are we “there” yet? Defining “there” is more gray than black and white. An AHI of 5 or less may be ideal but when a CPAP failure patient who started their journey with an AHI of 60 has been improved to 12, that may an incredible success. They may have more energy, less dependence on medications, reduced morbidities and a higher quality of life, but we are certainly not in a position as their dentist to determine if that is an acceptable treatment outcome. We should let the diagnosing provider make that call.

24 DSP | Winter 2019

After periodontal therapy, many patients can maintain their teeth in acceptable comfort, function and esthetics even if they have some residual pocket depths greater than 3

millimeters. Many clinically acceptable endpoints are not black and white, yet someone must make the call. As dentists, we are well trained to work interdependently with the periodontist to determine the survivability of the dentition in less than perfect outcomes, but we have far less expertise in medicine. The evaluation of the effectiveness of the outcome and the follow up responsibility for disease management is and should be in the realm of medicine. We should participate, but not direct or be responsible for the treatment efficacy or follow up for the development or recurring OSA, relevant symptoms or comorbidities. Nor should our partner in health care, the physician, direct the follow up care with regards to the fitting, adjustment, titration or replacement of the precision oral medical device that is driving the treatment. This policy emphasizes the obligation and importance of dentists in screening patients for OSA and outlines the importance of continued education in this field as well as the need to collaborate with physicians. This collaboration is designed to optimize the skill sets of the two professions and rein-

SPECIALfeature force the scope of practice in dentistry and medicine. Dentists are in a unique position to screen patients for SRBD as part of the comprehensive medical and dental history and, as healthcare professionals, they have the best expertise to evaluate the oral cavity and associated structures. Once appropriately screened, the patients should be referred to sleep physicians for a proper diagnosis. The ADA and the American Academy of Dental Sleep Medicine recognize that dentists play a critical and integral role in evaluating their patients with potential sleep-related breathing disorders but require the diagnosis of these disorders to be made by a physician. We are better together. When the treating dentist encourages the patient to return for the follow up sleep test to confirm the treatment efficacy, partnership strengthens. Patients feel better and have usually received some interim feedback like pulse oximetry to confirm they are on the right track. Without a follow up sleep test, we do not have verification. The best way to help the patient near the end of the treatment cycle is to have the conversation at the beginning of that cycle. By creating the expectation of a follow up test and maybe even including it in the written treatment plan, testing compliance will improve. Similarly, when physicians and dentists confer and create a treatment agreement document, it will help serve as a roadmap of treatment protocol for the collaborators.

Setting expectations up front for the professionals and patient improves outcomes and adherence. The ADA statement delineates the dentistâ&#x20AC;&#x2122;s role and clearly emphasizes the importance of communication by the dentist with the referring physician and other healthcare providers. The policy emphasizes that follow-up sleep testing by a physician is imperative to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities. Setting expectations The advent of home sleep tests (HST) has created some confusion and am- up front for the biguity as to who should perform and professionals and or interpret the post treatment efficacy studies. While dentists may utilize HST patient improves to assess the objective interim results of outcomes and Oral Appliance Therapy, the ultimate efficacy studies should be interpreted by adherence. the sleep physician. The complexity and comprehensive treatment of SRBD is best achieved when there is open communication between the treating dentist (with the proper training and expertise) and the sleep physician. The dentist managing a patient with SRBD using a mandibular advancement device should have a system for regularly evaluating their patients for ongoing use and efficacy. The ADA policy statement is consistent with the best practices approach to optimize treatment of SRBD and is in the best interests of our patients.

Mark T. Murphy, DDS, 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 DePaulâ&#x20AC;&#x2122;s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion.

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Dr. Edward T. Sall is Medical Director for ProSomnus Sleep Technologies. As Medical Director, Dr. Sall focuses on enhancing physician acceptance of Oral Appliance Therapy for patients with Obstructive Sleep Apnea. He obtained a DDS from Columbia University School of Dental and Oral Surgery in 1980. Due to his interest in facial pain and temporomandibular disorders, he decided to return to medical school for additional training. He attended SUNY Upstate Medical Center and received an MD in 1987, followed by a 5-year residency in Otolaryngology/Head and Neck Surgery. Since 1992, Dr. Sall has practiced in Syracuse, New York as an Otolaryngologist and Dentist with an emphasis on TMD, facial pain, general Otolaryngology and the surgical and medical management of sleep disorders. He obtained an MBA from SUNY Binghamton in 2000 with an emphasis in healthcare. Dr. Sall became board certified in Sleep Medicine and has treated over 3,500 patients with Oral Appliance Therapy.

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Special Section: ADA Policy Statement Part 2 by Jamison Spencer, DMD, MS, et al 1. A nationwide survey done by Goh found that medical students get ________ . a. A semester of sleep education in their second year of school b. Enough hours of sleep education to be confident diagnosing SRBD c. About three hours of sleep education d. Oral health education equivalent to most dental hygienists 2. Dentists have the advantage over physicians for SRBD therapy because ________ . a. We can diagnose OSA easier and cheaper than MDs can b. We can relate oral health patterns and skeletal issues to SRBD c. We don’t need to bother with medical billing problems d. We think more about people’s overall health than MDs do 3. Excellent care is separated from standard care by ________ . a. Comparing the fee charged for the service b. The details of the documentation of the steps involved c. How much doctor face-to-face time is spent with the patient d. The quality of communication between providers 4. The foundation of all medical judgments for

26 DSP | Winter 2019

each patient is ________ . a. The chief complaint b. The list of treatment options c. The diagnosis d. The procedures covered by the patient’s insurance 5. Treatment of SRBD is dependent on ________ . a. Managing jaw position to maintain comfort b. Titrating the mandibular position and addressing loop gain c. Providing adequate myofunctional therapy options d. The ability of the patient to tolerate CPAP 6. High Resolution Pulse Oximetry measures ________ . a. Pharyngeal and ventilatory instability b. Carbon dioxide levels as well as oxygen saturation c. Pulse wave forms with one-second intervals d. Physiologic data with sensitivity nearly as much as arterial blood gas tests 7. Without a follow up sleep test, we don’t have ________ . a. Any clue that the therapy is helpful b. Verification of efficacy c. To involve other professionals in therapy that we control d. The possibility of medical insurance coverage for our work

8. Complexity and comprehensive treatment of SRBD is best achieved with ________ . a. Open communication between treating dentist and diagnosing physician b. Using multiple appliances so the patient can choose the best result for them c. A thorough imaging protocol d. Making sure the ‘regular dentist’ is not also the ‘sleep dentist’ 9. Addressing the specific areas of oral airflow restriction has three primary surgical approaches, including: ________ . a. SFOT – Surgical Facilitated Orthodontic Therapy b. PAOG – Periodontally Accelerated Osteogenic Grafting c. RAPM – Regionally Accelerated Phenomenal Movement d. SHARPIE – Sure Handed Assisted Rapid Palatal Expansion 10. Maxillomandibular advancement surgery differs from traditional two-jaw orthognathic surgery ________ . a. In the time expected for the surgical procedure b. In the amount of recovery time and expected complications c. In magnitude and focus d. By the details of the pre-surgical orthodontic therapy

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LASERfocus

CO2 Laser Surgery Post-Operative Pain and Healing: A Partial Literature Review by Anna (Anya) Glazkova, PhD, and Peter Vitruk, PhD

Introduction

Postoperative pain and risk of infection are the main concerns with surgery. Most studies testing postoperative pain are level 5 (case report) evidence or animal studies. There are no randomized studies on the matter, leading to prevalent skepticism in the medical and dental communities about whether the surgical technique used relates to postoperative pain. However, the plethora of case studies and the ever-increasing amount of anecdotal reports in the field of patient pain perception following CO2 laser surgery indicate that there is basis for claiming reduced postoperative pain. This paper summarizes some of the existing research comparing postoperative pain and healing following CO2 laser surgery with conventional blade or scissors.

Healing, Myofibroblasts and PostOperative Wound Contraction

Studies of the soft tissue response to CO2 laser surgery1-25 have found reduced wound contraction (scarring) and delayed wound healing compared to scalpel surgeries. Slower healing of laser wounds (during inflammation and proliferation stages1,3,10) has been attributed to the narrow zone of tissue denaturation at the margins and the coagulation of some connective tissue elements, and also to temporary postponement of inflammation, phagocytic resorption, collagen production and re-epithelization in the early stages of repair.19 Since CO2 laser wounds are not as contracted as scalpel wounds, the larger surface area requires more time to re-epithelialize because cells have to migrate over a larger area.19 Zeinoun et al.10 reported a 3-day delay in re-epithelialization in CO2 laser wounds (the process was completed in 10 days in laser wounds vs. 7-days in scalpel wounds). Sanders et al.20 compared collagen thermal damage in pulsed and continuous-wave CO2 laser incisions and concluded that pulsing can reduce delay in healing. It has also been shown that delays in early stages of the CO2 laser wound healing are normally overcome at

28 DSP | Winter 2019

later stages and do not appear to influence long-term outcomes.21 Minimizing thermal damage through lower power settings and active tissue cooling helps minimize the delayed healing.9,20,22-25 Wound contraction and scarring during the remodeling phase of healing following CO2 laser surgery is reduced compared to scalpel surgery.2,10,11 Myofibroblasts are stromal cells derived from fibroblasts and possess contractile features in common with smooth muscle cells.26 They are key factors in fibromatosis and granulation tissue contraction during wound healing.26-28 Myofibroblasts have a specific capacity of developing cell-to-cell and cell-to-matrix connections thus acting on the whole tissue as a contractile network.29 It has been shown that reduced wound contraction correlates to the reduced number of myofibroblasts and connective tissue trauma.30,31 Zeinoun and colleagues10 analyzed the expression of myofibroblasts in healing CO2 laser excisions and control excisions made by scalpel in the dorsal tongue mucosa of 144 rats. This study found that myofibroblasts appeared and disappeared slower, and in significantly fewer numbers, in CO2 laser wounds. The lack of contractile myofibroblasts is suggested to be the reason for the minimal degree of contraction in healing CO2 laser excision wounds. Similar results were found by Fisher et al.1 and De Freitas et al.11 Luomanen et al.32 compared healing scalpel wounds versus CO2 laser wounds by looking at the extracellular matrix (ECM) components (such as laminin, Type IV collagen, Type III collagen, and fibronectin) in laser-treated rat tongue mucosa. The study found that laser treatment caused an extensive destruction of both epithelial and stro-

LASERfocus

mal cells but left much of the connective tissue matrix relatively intact. The regenerative processes with concomitant re-epithelialization occurred slower in laser-treated wounds. This study also noted that CO2 laser wounds differ drastically from burn wounds, which are characterized by the destruction of the connective tissue matrix, which results in notably more granulation tissue formation and wound contraction than is observed with healing of CO2 laser wounds.32-35 The study concluded that relative resistance of the ECM proteins to CO2 laser irradiation may account, at least partially, for the lack of contraction and scarring frequently observed in laser-treated areas. This may be another, less discussed, reason for less notable contraction of CO2 laser wound, in addition to the smaller number of myofibroblasts at the laser surgical site. To summarize, the following generalizations can be made based on the existing research about CO2 laser wound healing and myofibroblasts that contract tissue during wound repair:8,27,28 1. CO2 laser wounds have fewer myofibroblasts than scalpel wounds;1,10,11 2. CO2 laser wounds display less contractility than scalpel wounds;1,10,11 3. CO2 laser-wound healing results in less scarring;1,5,10

were left to heal by secondary intention. The postoperative pain and functional complications of each patient were recorded on days one and seven (a visual analog scale – VAS – was utilized). The CO2 laser frenectomy patients reported significantly less postoperative pain and fewer functional complications (e.g. speaking and chewing) The study concluded and required fewer analgesics in comparison with scalpel group patients. that “when used The study concluded that “when used correctly, the CO2 correctly, the CO2 laser offers a safe, effective, acceptable, and impressive laser offers a safe, alternative for frenectomy operations.” effective, acceptable, and In López-Jornet et al.15 study, 48 patients with oral leukoplakia were impressive alternative randomly assigned to receive treat- for frenectomy ment either with conventional scalpel surgery or with a CO2 laser. The site of operations.” scalpel surgery was sutured, while the laser wound was left to heal by secondary intention. A visual analog scale (VAS) was utilized to rate the intensity of pain and swelling at different postoperative time points. The patients reported that pain and swelling following scalpel surgery exceeded those with the CO2 laser (there were statistically significant differences between the two techniques during the first three days after surgery (p-value for related samples at 12 hours, 1, 2, and 3 days post-op ≤ 0.05). After that, pain gradually decreased over one week in both groups. The study concluded CO2 laser surgery caused minimal pain and swelling and it may be an alternative to scalpel surgery in treating oral leukoplakia.

Anna (Anya) Glazkova, PhD, is the clinical continuing education coordinator at LightScalpel, LLC.

Post-Operative Pain, Healing and Return to Function

Many studies have reported lower levels of pain and discomfort following CO2 laser surgery in oral soft tissues, compared with scalpel surgery.1,14,15,36,37 In Haytac et al.11 40 patients in need of frenectomy were randomly assigned to have treatment either with a scalpel or with a SuperPulse47 CO2 laser. The surgical wounds

Peter Vitruk, PhD, MInstP, CPhys, is a member of The Institute of Physics, United Kingdom, and a founder of the American Laser Study Club (www.americanlaserstudyclub. org), and LightScalpel, LLC (www.lightscalpel.com), both in the United States. Dr. Vitruk can be reached at 1-866-5892722 or pvitruk@lightscalpel.com.

DentalSleepPractice.com

LASERfocus In another study the CO2 laser was evaluated on 27 patients who underwent soft tissue pre-prosthetic surgery, including frenectomy, tuberosity reduction, hyperplasia removal, and sulcus deepening.4 The author pointed out that “it seems likely that discomfort is less after laser surgery than by more conventional techniques and it is definitely less than discomfort after conventional surgery with a secondary epithelialization technique. Swelling and edema were virtually nonexistent after laser surgery”. There was minimal swelling. Pain was moderate. Vestibular extension was created with mild-to-moderate discomfort, controlled with medium-strength an“It seems likely that algesics. “For frenectomies, the main advantages appear to be speed and a discomfort is less after clean, bloodless field.… For palatal laser surgery than by hyperplasia and soft tissue tuberosity reduction, the laser appears to be more conventional faster and cleaner with less discomfort techniques and it than is normally associated with this of surgery by other techniques”.4 is definitely less form A third of the patients did not need anthan discomfort algesics. Reduced wound contraction after conventional was observed. Niccoli-Filho et al.38 described 15 surgery... Swelling and cases where extensive epulis excision edema were virtually with maxillary or mandibular vestbuloplasty were carried out with a CO nonexistent after laser. Patients reported minimal dis-2 laser surgery”. comfort during the first 24 hours after the surgery, in stark contrast with conventional surgery experience with complaints of significant pain, sialorrhaea, dysphonia and dysphagia. For scalpel surgery patients, postoperative edema interfered with oral hygiene, further impairing healing. Overall, the study found that removal of epulis with the CO2 laser resulted in numerous notable improvements over conventional surgery, such as convenient removal of mucosa, lack of bleeding or need for sutures, and minimal postoperative pain and edema. In addition, the sites healed quickly, without complications, and both the esthetic and functional outcomes were excellent – all of the above allowed for more rapid placement of final prosthesis. Wlodawsky and Strauss39 presented several clinical cases showing CO2 laser applications in intraoral surgery, such as mucocele excision, sialolithotomy, frenectomy, gin-

30 DSP | Winter 2019

gival hyperplasia removal, vestibuloplasty, aphthous ulcer treatment, leukoplakia treatment, and others. One of their conclusions was that “the low morbidity and minimal pain generally associated with laser ablation makes it a valuable tool in the management of premalignant mucosal lesions.” Similarly, Mason et al.40 found low morbidity and minimal pain to be important post-operative outcomes following the removal of gingival fibromatosis. After the CO2 laser procedure, where the entire mouth was treated, no pressure packs were used and no sutures were placed. “Postoperative healing progressed with little discomfort or swelling and a satisfactory improvement in gingival contour and aesthetics was achieved.”40 In van der Hem et al.,41 39 oral lichen planus lesions in 21 patients were treated a with CO2 laser. Although this study was retrospective with no control group, the researchers pointed out the reduction in pain was an interesting result. Ishii et al.13 assessed the usefulness of CO2 laser treatment of oral leukoplakia lesions in 116 patients. The study found laser excision suitable for leukoplakia lesions on non-keratinized epithelia, while laser vaporization can be used for the gingival cases of non-homogenous type leukoplakia. The authors reported damage to adjacent tissue is minimal (which reduces acute inflammatory reaction and postoperative pain, swelling, edema or infection); wound healing is excellent due to the limited contraction and scarring; and typically it is possible to leave the surgical defect to heal by secondary intention, which keeps functional disorders to a minimum because regeneration can occur without leaving postoperative cicatricial contractures. The study concluded CO2 laser surgery was an excellent procedure for the management of oral leukoplakia which can prevent recurrence, malignant transformation, and postoperative dysfunction. To summarize, there are numerous reports of reduced postoperative pain, although not always predictable, following CO2 laser surgery.4,11,15,38-42 It was speculated to be the result of microcoagulation or “sealing” of nerve endings while severed nerve endings in scalpel wounds cannot anastomose.36 It was also claimed that neuromas do not form.36,43

LASERfocus

By sealing blood and lymphatic vessels and nerve endings, laser surgery significantly reduces the local inflammatory response, leading to lower levels of glucocorticoids, epinephrine and norepinephrine, lowering the pain level.

However, Basu3 found neuronal hyperplasia and traumatic neuroma in all wounds. He rendered Carruth’s hypothesis about “sealing” of nerve endings postoperatively unlikely and suggested that some other mechanism might be involved.3 The “nerve-sealing” theory also contradicts later research showing that the number of intact peripheral nerve structures in laser-treated sites was similar to the numbers in cautery- and scalpel-treated sites.44 This, again, leaves the reasons for reduced postoperative pain unclear. Another proposed explanation is based on the finding that the CO2 laser induces a spinal inhibitory effect via peripheral nerve stimulation, in other words, the activation of peripheral inhibitory nerves decreases neural signals from the spine to the cortex (gate theory).45 Contrary to this, Tran et al.46 documented a central somatosensory cortical effect of peripheral dermal stimulation with the CO2 laser. Decreased pain is sometimes attributed to reduced mechanical trauma to the tissue (Gama et al.,42 and others). In sum, while several possible explanations have been proposed over the years, the exact mechanism that is accountable for reduced postoperative pain in CO2 laser wounds compared to scalpel wounds is still unknown.

Recent Animal Studies on Post- and Intra-Operative Pain and Discomfort Carreira et al.16 compared postoperative pain and healing after CO2 laser surgery and

32 DSP | Winter 2019

scalpel surgery. Laser group patients exhibited lower pain levels and higher post-op comfort than those in scalpel group. The CO2 laser incisions were associated with lower white blood cell count (indicating reduced inflammatory response) and minor tissue trauma, because the endothelial wall does not incur as much injury as with scalpel incisions, thus decreasing the plasmatic protein total and serum albumin extravasation levels, and promoting healing. Carreira et al.17 studied intra-operative hemodynamic responses (heart rate, various blood pressure parameters) in patients under general anesthesia and concluded that CO2 laser was perceived as less painful than scalpel surgery. By sealing blood and lymphatic vessels and nerve endings, laser surgery significantly reduces the local inflammatory response, leading to lower levels of glucocorticoids, epinephrine and norepinephrine, lowering the pain level. Silva et al.18 compared the plasma C-Reactive Protein (CRP) level variation between CO2 laser surgery and scalpel surgery patients. CRP is an acute (inflammation) phase response protein. Peri-operatively, plasma CRP levels can help monitoring the level of tissue inflammation – the level of CRP correlates with the surgical trauma intensity in the patient. For CO2 laser surgery patients, lower plasma CRP levels were registered than for scalpel group patients, i.e. the CO2 laser in surgery was associated with lower inflammatory response, promoting a more comfortable peri-operative period for the patient. Thus, all three above studies have shown that CO2 laser incisions are associated with reduced inflammatory response, less postoperative pain, and better healing.

Summary Several studies have found the reduced presence of contractile myofibroblasts – cells accountable for postoperative scarring – in CO2 laser surgical wounds when compared to scalpel surgery. The authors of this review believe both the reduced production of myofibroblasts and reduced post-operative pain can be partially explained by the optimal depth of coagulation/hemostasis47 on CO2 laser surgical margins. Decreased extravasa-

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LASERfocus tion of blood and lymphatic fluids into the CO2 laser wound space impedes the release of inflammatory mediators.19 This results in less edema around the wound than following conventional surgery and delayed minimal inflammatory response.1,48 It may also account for the reduced immediate postoperative pain after CO2 laser surgery. Despite the abundant research and anecdotal reports regarding diminished pain following CO2 laser surgery, the exact mechanism behind it remains to be explained.

20.

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24. 25.

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10. 11.

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18.

19.

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Fisher SE, et al. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch. Oral Biol. 1983;28(4):287-291. Fisher SE, et al. The effects of the carbon dioxide surgical laser on oral tissues. Brit J Oral Maxillofac Surg. 1984;22:414-25. Basu MK, et al. Wound healing following partial glossectomy using the CO2 laser, diathermy and scalpel: a histological study in rats. J Laryngol Otol. 1988;102(4):322-7. Pogrel MA. The carbon dioxide laser in soft tissue preprosthetic surgery. J Prosthet Dent. 1989; 61:203-8. Luomanen M, et al. Extracellular matrix in healing CO2 laser incision wound. J Oral Pathol. 1987;16:322-31. Luomanen M. A comparative study of healing of laser and scalpel incision wounds in rat oral mucosa. Scand J Dent Res. 1987 Feb;95(1):65-73. Luomanen M, et al. Healing of laser and scalpel incision wounds of rat tongue mucosa as studied with cytokeratin antibodies. J Oral Pathol. 1987 Mar;16(3):139-44. Luomanen M, et al. Healing of rat mouth mucosa after irradiation with CO2, Nd:YAG, and CO2-Nd:YAG combination lasers. Scand J Dent Res. 1994;102(4):223-8. Wilder-Smith P, et al. Incision properties and thermal effects of three CO2 lasers in soft tissue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995; 79(6):685-91. Zeinoun T, et al. Myofibroblasts in healing laser excision wounds. Lasers Surg Med. 2001;28:74-79. de Freitas AC, et al. Assessment of the behavior of myofibroblasts on scalpel and CO2 laser wounds: an immunohistochemical study in rats. J Clin Laser Med Surg. 2002;20(4):221225. Zaffe D, et al. Morphological histochemical and immunocytochemical study of CO2 and Er:YAG laser effect on oral soft tissues. Photomed Laser Surg. 2004;22(3):185-189. Ishii J, et al. Management of oral leukoplakia by laser surgery: relation between recurrence and malignant transformation and clinicopathological features. J Clin Laser Med Surg. 2004;22(1):27-33. Haytac M, et al. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol. 2006;77(11):1815-19. López-Jornet P, et al. Comparison of pain and swelling after removal of oral leukoplakia with CO2 laser and cold knife: A randomized clinical trial. Med Oral Patol Oral Cir Bucal. 2013;18(1):e38–e44. Carreira LM, et al. Comparison of the Influence of CO2-laser and scalpel skin incisions on the surgical wound healing process. ARC J Anesthesiol. 2016;1(3):1-8. Carreira LM, et al. Comparison of the hemodynamic response in general anesthesia between patients submitted to skin incision with scalpel and CO2 laser using dogs as an animal model. A preliminary study. ARC J Anesthesiol. 2017;2(1):24-30. Silva L, et al. Comparative Study on the Plasmatic CRP Level Variation in Dogs Undergoing Surgery with CO2 Laser and Scalpel Blade Incisions in a Pre- and Post-Surgical Time-Point. ARC J of Anesthesiol. 2018;3(4):3-11. Hendrick DA, et al. Wound healing after laser surgery. Otolaryngol Clin North Am. 1995;56:969–86.

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Sanders DL, et al. Wound healing and collagen thermal damage in 7.5-microsec pulsed CO(2) laser skin incisions. Lasers Surg Med. 2000;26(1):22-32. Fry TL, et al. Effects of laser, scalpel, and electrosurgical excision on wound contracture and graft “take”. Plast Reconstr Surg. 1980 Jun;65(6):729-31. Finsterbush A, et al. Healing and tensile strength of CO2 laser incisions and scalpel wounds in rabbits. Plast Reconstr Surg. 1982;70:360-2. Filmar S, et al. A comparative histologic study on the healing process after tissue transection: II: Carbon dioxide laser and surgical microscissors. Am J Obstet Gynecol. 1989;160:106872. Hall R. The healing of tissues incised by a carbon-dioxide laser. Br J Durg. 1971;58:222-5. Moreno R, et al. Epidermal cell outgrowth from CO2 laser- and scalpel-cut explants: Implications for wound healing. J Dermatol Surg Oncol. 1984;10:863-8. Hinz B, et al. Mechanical tension controls granulation tissue contractile activity and myofibroblast differentiation. Am J Pathol. 2001;159(3):1009–20. Darby IA, et al. Fibroblasts and myofibroblasts in wound healing. Clin Cosmet Investig Dermatol. 2014;7:301–11. Hinz B. Formation and function of the myofibroblast during tissue repair. J Invest Dermatol. 2007;127(3):526–37. Hinz B, et al. Myofibroblast development is characterized by specific cell-cell adherens junctions. Mol Biol Cell. 2004;15(9):4310–20. Schurch W, et al. The myofibroblast: a quarter century after its discovery. Am J Surg Pathol. 1998;22:141–7. Robbins SL, et al. Inflammation and Repair. Philadelphia: WB Saunders; 1984;40–84. Luomanen M, et al. Extracellular matrix in healing CO2 laser incision wound. J Oral Pathol. 1987;16:322-31. Ehrlich HP, et al. A comparative study of fibroblasts in healing freeze and burn injuries in rats. Am J Pathol. 1984 Nov;117(2):218-24. Fujikawa LS, et al. Fibronectin in healing rabbit corneal wounds. Lab Invest. 1981;45-120. Bertolami C, et al. The effect of full-thikness skin grafts on the actomyosin content of contracting wounds. Oral Surg. 1979; 37- 471. Carruth JAS. Resection of the tongue with the carbon dioxide laser. J of Laryn and Otol. 1982;96:529-43. Colvard M, et al. Managing aphthous ulcers: laser treatment applied. J Am Dent Assoc. 1991;122:51–3. Niccoli-Filho W, et al. Removal of epulis fissuratum associated to vestibuloplasty with carbon dioxide laser. Lasers in Medical Science. 1999;14(3):203–6. Wlodawsky RN, Strauss RA. Intraoral laser surgery. Oral Maxillofac Surg Clin North Am. 2004 May;16(2):149-63. Mason C, et al. The use of CO2 laser in the treatment of gingival fibromatosis: a case report. Int J Paediatr Dent. 1994;4(2):105109. van der Hem PS, et al. CO2 laser evaporation of oral lichen planus. Int J Oral Maxillofac Surg. 2008 Jul;37(7):630-3. doi: 10.1016/j.ijom.2008.04.011. Epub 2008 Jun 6. Gama SK, et al. Benefits of the use of the CO2 laser in orthodontics. Lasers Med Sci. 2008 Oct;23(4):459-65. Holzer P, et al. Laser surgery of peripheral nerves. In: Kaplan I, ed. Laser Surgery III, part one. Tel-Aviv:OT-PAZ; 1979:149–53. Rocha EA, et al. Quantitative evaluation of intact peripheral nerve structures after utilization of CO2 laser, elecrocautery, and scalpel. J Clin Laser Med Surg. 2001;19:121–6. Weng HR, et al. Nociceptive inhibition of withdrawal reflex responses increases over time in spinalized rats. Neuroreport. 1996;7:1310–4. Tran TD, et al. Cerebral activation by the signals ascending through unmyelinated c-fibers in humans: a magnetoencephalographic study. Neuroscience. 2002;113: 375–86. Riek C, Vitruk P. Incision and Coagulation/Hemostasis Depth Control During a CO2 Laser Lingual Frenectomy, Dent Sleep Practice. Spring 2018:32-8. Pogrel M, et al. A comparison of carbon dioxide laser, liquid nitrogen cryosurgery, and scalpel wounds in healing. Oral Surg Oral Med Oral Pathol. 1990;69:269-73.

PRODUCTfocus

A Perspective on Case Acceptance in DSM by Mark T. Murphy, DDS, D.ABDSM

often observe offices with systems for Dental Sleep Medicine (DSM) that mirror what they did as dentists; discretionary patient expenditure, no real insurance, coverage limitations and little urgency. Systems are in place for the dental team and not the patient, making it easier for them to choose NOT to do necessary treatment. In medicine, the scene is different, and choices are made with more physician direction to the players. Full or large down payments, comprehensive explanations of outof-pocket costs and rigid comprehensive examination protocols before the patients say YES can make DSM less fulfilling than it should be. Dentistry is NOT Like Medicine

Although there are a very few patients who want or need to know every possible expense in medical care scenarios, most will move forward without a very clear picture of ‘how much.’ Less than half of the patients we see ever ask us how much the oral appliance will cost and, when we tell them it is covered by their medical insurance, most of those are satisfied. The few that remain wonder what their maximum out-of-pocket expense could be – we tell them it is the same as what a familiar regional insurance carrier approves. That settles it. They feel comfortable because a third party (the familiar medical insurance carrier) has sort of verified and validated our fee.

Patients want to know three important things in making their decisions in medicine; 1. Do I have this condition or disease? 2. How serious is it? 3. Is it treatable/curable/manageable? Most do not ask how much it will cost or what will need to be done in the course of treatment. If they do, it is after these three questions are answered. We use five intentional tools that help patients on that journey. • The SnoreLab app helps patients understand how problematic their OSA can be to bedpartners. • A take home copy of the STOP BANG puts perspective on disease risk if they do not already have a sleep test. • An eight-slide deck clarifies the comorbidities and severity of this disease, etiology and treatment options. • Our snore test (have patient make snoring sound, then have them hold their lower jaw forward for quiet breathing) gives them treatment hope. • We show them a demo model of a small profile, precision engineered device like the ProSomnus® [IA] or the Precision Herbst [PH] for Medicare patients to show them how easy the treatment will be.

The SnoreLab app

Mark T. Murphy, DDS, D.ABDSM, 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.

36 DSP | Winter 2019

Give Patients What They Want

ProSomnus® [IA] appliance

Precision Herbst [PH] appliance

Keep it simple, answer questions that are asked, not anticipated. This is medicine – not dentistry. You will have much more success with your treatment acceptance and help more patients.

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MARKETING

Growing a Dental Sleep Practice: Step 3 – Online Promotion by Marc Fowler

his is the third in a series of articles focused on effectively attracting sleep patients through digital branding and marketing. In the previous two articles we discussed the importance of creating a brand identity for sleep that is independent of your general dental practice brand and generating supporting assets that position you as the recognized authority in your market. The third step in implementing a successful direct-to-patient digital marketing strategy is proactively promoting your sleep practice online. In other words, letting potential sleep patients know that you exist and that you offer an excellent solution to their sleep breathing issues.

Pro Tip: Having a separate sleep website increases your visibility when Attracting Sleep Patients Organically perspective patients There are two ways to gain visibility are searching on online. The quickest and most expensive Google for sleep method is to pay for exposure via advertising. Google, Facebook and YouTube all offer apnea related terms. comprehensive advertising platforms. We’ll look at these in a future article. Today, let’s focus on the second method: gaining organic visibility. Organic visibility simply means positioning your sleep practice to be found by prospective patients online without paying for advertising clicks. You want to show up prominently for searches like “sleep apnea” and “snoring solutions”. It’s no secret that Google is the 800-pound online gorilla. According to Statcounter, as of November 2018, Google controlled 87% of the U.S. search engine market, with Yahoo, Bing, DuckDuckGo and MSN fighting over the remaining 13%. Given Google’s dominance, the focus of your online efforts need to be on optimizing for Google. As a local business, the best place to start is taking control of your Google My Business (GMB) listing. A properly optimized GMB listing can drive a significant volume of

38 DSP | Winter 2019

website traffic and phone calls. The article in the prior issue provides details on how to optimize your listing and show up prominently in Google’s Local Pack (also known as the Map Pack). After optimizing your GMB listing, you should focus next on your website. One of the many advantages of having a dedicated sleep website is that it sends a clear signal to Google about your practice being sleep-focused. Effectively associating your sleep website with the most frequently searched sleep breathing related terms is a critical step towards building organic visibility and attracting sleep patients from the internet. There are over 200 factors that Google considers when deciding which websites to return in a search results page. A deep dive into Google’s algorithm is beyond the scope of this article, so we’ll look at two of the more important factors. First is on-page or technical search engine optimization. That is, what’s happening on your website – within the code. I’m referring to things such as title tags, site maps, internal links, etc. These elements help build your website’s relationship to the target keywords. I highly recommend you contact someone with experience in on-page SEO. Getting it right can provide a significant boost, getting it wrong can leave you virtually invisible online. User experience is another important factor for improved visibility. Is your website mobile-friendly, easy to navigate and does it load fast? Google tracks this data, as well as factors such as which pages are visited the most, which pages result in the most site exits, and time spent on site. Yes, Google tracks how long visitors stay on your website. The longer a visitor stays, the better. Google assumes that a longer average visit time means that your site has valuable content and is appropriately related to the search term that brought the visitor to your site. This helps

MARKETING Google determine the quality and relevance of your website. In addition to what’s happening on your website, off-page factors also play a significant role in Google rankings. This starts with the quality and quantity of inbound links (websites that point traffic to your website). If Google sees other websites linking to your website, they assume you must be providing valuable content and be an authority on the topic. Another important off-page factor in your Google rankings are citation signals. A citation is a reference to your practice’s name, address and phone number online. Unlike links, citations do not need to link back to your website. Just having your information listed online gets you credit for a citation. Businesses that are mentioned frequently online and have consistent information across their citations are viewed as being more credible to Google.

Building organic visibility for your sleep practice is a marathon, not a sprint. When the activities outlined above are done correctly and consistently over a period of time, you will see a significant positive impact on the success of your sleep practice. If you’d like to take a deep dive into the unique organic visibility opportunities available in your market, give me a call. My direct line is 214-592-9393. Alternatively, you may visit BullseyeDental.com/Call to schedule time on my calendar.

Having video on a website increases the length of time visitors spend on the site by

% 88 – Forbes

Marc Fowler is the founder of Bullseye Media, LLC. Since 2006, the team at Bullseye Media has helped hundreds of dental practices across the U.S. and Canada leverage the internet to achieve their practice growth goals. Learn about their turnkey direct-to-patient sleep marketing program at DentalSleepMarketing.com.

THE 3 STEP MODEL FOR GROWING A DENTAL SLEEP PRACTICE Discover the direct-to-patient system that is working for successful dental sleep practices nationwide.

Visit DentalSleepMarketing.com

DentalSleepM arketing.com

DentalSleepPractice.com

PRODUCTstudy

The Oventus O2Vent Optima Nylon Appliance ®

by John Viviano, DDS, D.ABDSM

he Oventus O2Vent line of oral appliances recently added the O2Vent Optima. The Optima achieved 510k market clearance from the US Food and Drug Administration late this summer. The Optima is available in Canada, the US and Australia. The Oventus focus is on this newly available entry into market. The original O2Vent, based on a Mono Block platform, incorporated an integrated oral breathing channel. It allowed for mandibular advancement, but this required lab participation. Chairside adjustable versions were then introduced; one based on a “TAPLike” anterior midpoint attachment and a second based on a “Dorsal-Like” bi-lateral attachment – O2Vent® T and O2Vent® W. The latest addition to this lineup of appliances is the O2Vent Optima (Figure 1). It is designed and manufactured in a Computer Assisted Design and Computer Assisted Manufacturing (CADCAM) environment. It is best described as a hybrid appliance blending features of EMA and Narval devices with the integrated airway technology that is unique to Oventus oral appliances. The O2Vent Optima is made of PA2200 non-filled type 12 Polyamide Nylon, and is 3D Printed. As with all of the Oventus O2Vent appliances, mandibular advancement is provided along with the integrated proprietary airway technology which facilitates airflow even during velopha-

Figure 2: ExVent PEEP Valve

40 DSP | Winter 2019

Figure 3: Oventus O2Vent Optima + ExVent (PEEP Valve)

Figure 1: Oventus O2Vent® Optima

ryngeal collapse. Mandibular advancement is achieved using Oventus proprietary medical grade Isothane connector bands developed specifically for the Optima. The O2Vent Optima is provided fully assembled with a 19 mm length connector band attached, customized to the patient needs. Two sets of connector bands are also provided to adjust advancement, each set consisting of 9 sizes ranging from 13-21. As with all appliances that utilize connector bands, once the optimum jaw posture is established, the advancement bands should be assessed monthly for elongation and replaced as necessary.

The O2Vent Optima Advantage

The Oventus O2Vent Optima can be very useful for chronic nasal obstructers, but it can also be used for non-nasal obstructers. A non-nasal obstructer will breathe normally through their nose while wearing the O2Vent Optima, however, during allergy or cold season, if their nasal breathing becomes temporarily compromised, they can also benefit from the airway option. The premise of the O2Vent Optima is that the integrated airway channel by-passes the problematic velopharyngeal blockage area thus reducing negative pharyngeal pressure swings.

PRODUCTstudy

Figure 4: Titratable Oral/Nasal PEEP Valve (prototype)

The ExVent is an accessory to the Optima device. The addition of this Positive End Expiratory Pressure (PEEP) valve helps to stabilize end expiratory pressure and maintain a positive airway pressure, preventing airway collapse (Figure 3). The ExVent Oral PEEP valve was introduced into the Australian and Canadian market in the spring of 2019. A multi-center trial with the ExVent is being conducted within the United States. For those PAP users struggling with Full Face Mask or those complaining of being starved for air, the ExVent offers a new therapeutic alternative. Even more exciting are two innovative products currently in the research and development phase of product realization at Oventus Manufacturing in Brisbane, Australia. The first product is a combination of oral and nasal PEEP (Figure 4). The valve-pillow combination will attach to the O2Vent Optima or the O2Vent W appliances. It is being designed as a potential alternative treatment to CPAP. Patients may receive similar benefits without a 1lb. device, hose, mask and a power requirement. The second product is a Connector that fits to CPAP (Figure 5). The PAP Connector will allow PAP to be applied without straps or the traditional PAP mask. Both of these innovative products are exciting and currently in development.

Why Focus On PEEP?

Since excessive increase in expiratory resistance can result in CO2 retention and patient awakening, successful therapy with PEEP devices depend on clinical expertise and selection of an appropriate resistance that allows the patient to continue breathing

Figure 5: Connect to Pap (prototype)

normally without significant CO2 retention. An ideal PEEP device should increase the expiratory pressure without compromising tidal volume, without causing CO2 retention, and without disturbing sleep. The Oventus design is being developed as a platform which revolves around the notion of achieving optimal success with minimal intervention. The airway channel manages mouth breathing and by-passes the problematic velopharyngeal blockage area — this seems to be counter-intuitive considering what we know about the importance of nasal breathing. However, O2Vent appliances do not promote mouth breathing for a patient that has good nasal patency, they simply manage mouth breathing for those patients that have compromised nasal breathing. We know that there is a subset of

Dr. Viviano obtained his credentials from the University of Toronto in 1983. His clinic is limited to managing sleep-disordered breathing and sleep-related bruxism. He is a Credentialed Diplomate of the American Board of Dental Sleep Medicine and has lectured internationally, conducted original research, and authored original articles on the management of sleep-disordered breathing. His clinic is the first Canadian facility accredited by the American Academy of Dental Sleep Medicine and he is Clinical Director of the Sleep Disorders Dentistry Research and Learning Centre. Dr. Viviano also hosts the SleepDisordersDentistry LinkedIn Discussion Group and conducts dental sleep medicine CE programs for various levels of experience, including a 4-day mini residency. Dr. Viviano’s Class and Cloud Based CE programs can be found on SDDacademy.com, and he can be reached at (905) 2127732 or via the website sleepdisordersdentistry.com. Disclosure: Dr. Viviano reports no disclosures.

DentalSleepPractice.com

PRODUCTstudy patients that remain nasally compromised, even post-surgical intervention, and this may be the appliance of choice for them. However, this approach may benefit even those patients with optimum nasal breathing. There is some suggestion in the literature that an OSA Appliance is more likely to fail when the site of collapse is at the velopharynx (Figure 6). For patients who experience a velopharyngeal collapse, the oral breathing chamber facilitates air flow caudal to the velopharyngeal collapse, allowing for uninterrupted ventilation (Figure 7). Of course, nasal breathing is preferable for a number of reasons, one of the most important being the function of the nasal valve which moderates the rate of breathing. I wonder if the planned PEEP valve could in fact mimic this same function for oral breathing?

Figure 6: Site of Pharyngeal Collapse Related to Oral Appliance Success

Figure 7: O2Vent Airway Technology Channel Bypasses Collapse at Velopharynx

42 DSP | Winter 2019

Show me the Evidence

In 2017, Lavery et al. published their findings on the safety and efficacy of the Oventus 02Vent Mono Block appliance for the management of Obstructive Sleep Apnea. The study had an n of 29, and incorporated participants of relatively severe OSA. They concluded that this device is safe, effective, and well tolerated with a clinically and statistically significant reduction in AHI of 62% as well as improvement in oxygen saturation. Neither efficacy nor response was reduced by the presence of nasal obstruction. There has been much ongoing research activity in Australia regarding the Oventus O2Vent appliance platform. In October 2018, five abstracts were presented by various groups at the European Respiratory Society International Congress and the Sleep Down Under Annual Conference. â&#x20AC;˘ AIRWAY OPEN-AIRWAY CLOSED: Lavery, Szollosi, Moldavtsev, McCloy and Hart This study with an n of 32 aimed to determine the effects of the built-in airway on treatment response measured using the Apnea Hypopnea Index (AHI). The results demonstrated the benefit of adding an Oral Airway. The addition of an Oral Airway to proven non-responders reduced their residual AHI a further 20% and resulted in 6 of the 17 non-responders becoming Oral Appliance Responders. Overall, the authors found that treatment response was similar with and without an Oral Airway, with much inter-individual variability. However, when a significant differential response occurred, it more frequently favored the Oral Airway. Patients that failed to respond to traditional Oral Appliance treatment with no Oral Airway, and those with higher inspiratory nasal resistance, tended to respond more favorably to an Appliance with an Oral Airway. â&#x20AC;˘ Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces OSA severity: Lai, Tong, Tran, Ricciardeiello, Donegan, Murray, Carberry and Eckert This study of n=22, aimed to determine if combination therapy with an oral appliance that has a built-in

PRODUCTstudy oral airway (O2VentT™) and Oral or Oro-Nasal PEEP valves, reduces OSA severity for incomplete oral appliance responders. It demonstrated that the addition of both Oral and Oro-Nasal PEEP valves to the base appliance that had an Oral Airway resulted in a reduction in OSA severity to therapeutic levels for approximately 60% of participants who were incomplete responders to the appliance alone. They also found that addition of the Oral PEEP valve significantly reduced residual events by 30% (p<.02) and that the addition of Oro-Nasal PEEP valves significantly reduced residual events by 50% (p<.02). • Combination therapy with CPAP plus MAS reduces CPAP therapeutic requirements in incomplete MAS responders: Tong, Tran, Ricciardiello, Donegan, Murray, Chiang, Szollosi, Amatour, Carberry and Eckert Preliminary results (n=16) of a study investigating the combination of PAP with an Oral Appliance for incomplete Oral Appliance Responders resulted in approximately 35-45% lower PAP pressure requirements and normalized pharyngeal pressure swings to a level similar to PAP alone. The results were similar with and without an Oral Airway, indicating that patients can continue to breathe through the device airway while delivering nCPAP without losing airway stability eliminating the need for full face masks. • Postural effects on nasal resistance in obstructive sleep apnoea (OSA) and efficacy of a novel oral appliance: Tong, Tran, Ricciardiello, Donegan, Murray, Chiang, Amatoury, Carberry and Eckert This study of n=39 aimed to assess the effects of posture and mandibular advancement on nasal resistance in people with OSA, and determine the efficacy of a novel oral appliance that incorporates an oral route of breathing in people with OSA, including those with high nasal resistance. The results showed that nasal resistance increased not only from the seated to the supine position but increased again in the lateral position.

The Oventus O2Vent reduced AHI by approximately 50% with similar reductions in those with and without increased nasal resistance. • Predictors of Response to a Novel Mandibular Advancement Device (Oventus O2Vent T) in patients with OSA: Walsh, Maddison, Baker, Pantin, Lim, Szollosi, McArdle, Hillman and Eastwood Preliminary results (n=22) of a study designed to investigate predictors of response to an appliance with an Oral Airway demonstrated that the Oventus O2Vent reduced AHI by approximately 40% with the Oral Airway open or closed. The results demonstrated an even better result for those patients with lower nasal resistance. The authors concluded that access to oral breathing may be of benefit for certain subgroups; females, smaller neck circumference and lower waist/hip ratio.

The Oventus design is being developed as a platform which revolves around the notion of achieving optimal success with minimal intervention. The innovative and unique Oventus treatment platform is being designed to provide the ability to move through various steps of intervention, beginning with simply the base appliance, the Oventus O2Vent Optima, and progressing to the addition of a simple PEEP valve, a titratable Oral-nasal PEEP valve and finally the addition of PAP. The platform allows for adaptability to a next level of therapy if the current therapy step has less than desired efficacy of treatment such as residual apnea or persistent symptoms. Although the science is early and immature, the concept is certainly intriguing and worthy of further investigation; by-passing the problematic velopharynx and/or nasal patency issues, the addition of Positive End Expiratory Pressure control and making this resistance titratable, and finally the addition of PAP if necessary. While we are waiting for more evidence, for those patients that are nasally compromised, this appliance may be the answer. DentalSleepPractice.com

TEAMfocus

Are You Ready for 2020?

by Glennine Varga, AAS, RDA, CTA

re you ready? As we approach 2020 there are many things I’m excited about that will bring awareness to your dental sleep medicine practices across the US. New technology, public awareness and collaboration all will play a role in patients asking dentists about sleep breathing and optimal airway health. Again I ask, are you ready? For over 20 years I’ve witnessed the dental profession identify how dental professionals can make an impact on airway health. In the past two years, the volume has increased tremendously. More and more patients are asking about it, physicians are reaching out to dentists asking if they can help, companies and corporations are creating products and services specifically for our industry. Let’s dive into these things I’m excited about and identify how team can get involved.

44 DSP | Winter 2019

I have had the honor of working with hundreds of dental offices that are incorporating sleep breathing disorders into their practices. Most will ask which software should I get? My answer is to check them all out! What it comes down to is how well the system works in your hands. It’s like your phone – you’ve got to know how to work it because you will be using it daily. I’m excited for the new system MD Fusion and Lyon Dental. They offer a cloud-based documentation system and medical billing services. Like Dental Sleep Solutions (DS3), the system was created by a practicing and board-certified DSM dentist. My go-to is DentalWriter – I’m biased because I used it in practice and trained on it for 10 years. Also, I love the team. They are very informative - Rose Nierman does a great job of keeping everyone up to date on the changing landscape of DSM. Rhinomanometer by BioResearch is not new technology. BioResearch, a 50 plus year old company in Milwaukee, is introducing

1 in every 3 patients have some form of bruxism.

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TEAMfocus This industry is growing and will continue to improve on patient’s ability to get a good night’s sleep and improved overall health and wellness.

this technology to the dental field for the first time. Many DSM dentists have heard of rhinometry which is acoustic measurements of the nose. Rhinomanometry is different as it measures nasal air flow, which allows dentists and team to evaluate if flow limitation plays a role which may require a referral to an otolaryngologist or incorporating nasal dilators like MaxAir Nose Cones or Mute. People with a nasal flow limitation adapt to it as do our structures and systems. When this phenomenon is identified and corrected, we rejoice because when nasal flow increases it makes us very happy. If this can be identified in a growing child, the structure can be influenced in several ways to improve the airway. Treating adult patients with oral appliances should always be a wonderful service to provide. Identifying problems in children can improve their sleep, cognition, mood, health, social interaction and dental health. WOW what a great profession to be in! I’m so excited for our future! Collaboration of professions and public awareness is starting to increase. The time is here for physicians and dentists to work more closely to identify and increase airway possibilities for patients. October 2, 2019, (O2) was the inaugural Global Airway Health

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

46 DSP | Winter 2019

Day! Start preparing your efforts early for 2020, celebrate it and have fun doing it. I envision pajamas, buttons, signs and eye masks - anything to bring awareness to this great day! Visit https://airwayhealth.org for more information. Also, there are many organizations offering CE in sleep breathing, airway or OSA. Plan out your year of CE! I’m excited about Pankey Institute’s Advanced Airway course, the American Academy of Dental Sleep Medicine’s (AADSM) Business of DSM course and the American Dental Association’s (ADA) Children’s Airway Conference. Your next team meeting can include the following action items: • Evaluate your office and the use or non-use of technology. If you already have technology, refresh yourself with the training and ways to introduce it to your patients. If you do not, check out ways to evaluate nasal flow as well as screening for sleep breathing disorders. • Check out ancillary items such as nose cones, white noise apps, and humidifiers. As public awareness increases you want your patients to know you offer airway therapies. Pick up some ancillary items to accompany your oral appliance therapy or simply display information regarding them. • Plan Global Airway Health Day 2020. Start your airway awareness campaign now and keep it going all year round. Yes, there is a day for it, but it should be celebrated every day or at least discussed with your patients. Everyone breathes every day, right? • Take time for Continuing Education. It’s always good to get educated. The more you are exposed to airway topics the better you will be able to spread the word throughout your office. Not to mention CE trips should be fun and a great time to bond as a team! I’m confident our patients are in great hands and I’m happy this industry is growing and will continue to improve on patient’s ability to get a good night’s sleep and improved overall health and wellness. Thank you to DSP and Dr. Steve Carstensen for your combined efforts over the past 5 years of great editorial content!

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*Gagnadoux F, et al. Comparison of titrable thermoplastic versus custom-made mandibular advancement device for the treatment of obstructive sleep apnoea. Respir Med. 2017 Oct 1;131:35â&#x20AC;&#x201C;42.

PRODUCTspotlight

TMJ & Sleep Therapy Centre International

MJ & Sleep Therapy Centre International, headquartered in La Mesa, California, is a leader in the field of continuing education, training and resources for the dental healthcare profession.

“I can help far more patients if I share and teach other professionals what I have learned and tested …” – Dr. Steven Olmos

48 DSP | Winter 2019

Offering continuing education courses for professionals seeking more knowledge in the fields of craniofacial pain and sleep related breathing disorders. For more than 15 years, they have been providing an integrated approach to patient care for adult and pediatric patients with sleep-related breathing disorders, and for the full range of craniofacial pain, including facial neuralgia, orthopedic dysfunction of the TM joints, musculoskeletal pain, and primary headaches (migraine, tension, cluster). They understand the complexities of craniofacial pain and sleep disorders — how they overlap and how they impact the lives of millions. The TMJ & Sleep Therapy Centres commitment is two-fold, providing education and training for the global professional community treating these patients, and providing care for patients in their “Centres of Excellence” around the world, over 60 centres in 7 countries. Their course objectives include in-depth diagnosis, triage, the most current diagnostic and treatment technologies, patient management systems, and training at all levels of a dentist’s practice. All education is directed by Dr. Steven R. Olmos, an internationally recognized lecturer, researcher, and the founder and CEO of TMJ & Sleep Therapy Centre International. Dr. Olmos graduated from the University of Southern California School of Dentistry and has dedicated the past 30 years to the fields of craniofacial pain, and sleep-related breathing disorders for adults and children. He has extensive post graduate education and board certifications in both craniofacial pain and dental sleep medicine. This effort is focused to establish protocols between dentistry and medicine for optimal treatment outcomes. We encourage you to expand your knowledge by taking one of

Dr. Steven R. Olmos is the founder and CEO of TMJ & Sleep Therapy Centre International

their courses and connecting with their team of experts. “My diagnosis and treatment focus have changed dramatically over the last few years to a more simple, conservative delivery with greater efficacy. Helping people is my goal and I can help far more patients if I share and teach other professionals what I have learned and tested,” says Dr. Steven Olmos, Founder and CEO of TMJ & Sleep Therapy Centre International. To learn more about TMJ & Sleep Therapy Centre International and see all of the courses they offer, visit www.tmjtherapycentre.com or call 877-864-4325 to speak directly with an education administrator. Check them out at Booth #816 and be sure to use code GNYDM for a special rate!

PRODUCTspotlight

The SnoreHook Splint

New Medicare-Approved Device is a Game-Changer for the Sleep Practice

ncreasing laboratory fees, decreasing insurance reimbursement, costly remakes, lengthy turnaround times, and patient intolerance can significantly impact the operating costs and satisfaction of running a dental sleep practice. The SnoreHook Splint, the new FDA-cleared and PDAC-approved device was designed to both minimize the cost and time invested in treating OSA. Combining the proven technology of an anteriorly positioned advancing hook mechanism with newly patented pre-engineered trays and thermoplastic adapting putty, the SnoreHook Splint allows a practitioner to fabricate a durable treatment device in-office in less than 30 minutes for approximately 15% of the typical lab fee. Other attractive features include: • Lifetime warranty on parts and components • Easily adjusted, modified or re-fit • Ideal as a “back-up” or interim device Practitioners can request a free sample to fabricate one on themselves for valuable insight. Volume discounts are available. Visit www.SnoreHook.com to learn more.

50 DSP | Winter 2019

SnoreHook Splint Highlights FDA and Medicare approved E0486 No lab fee 20-minute in-office fabrication $78 per set of components Easy to modify and/or repair Long term durability, yet ideal as interim Cost-effective back-up device Perfect “loaner” while other device is in the shop Lifetime warranty on parts and materials When you need it now Can be made anywhere “in the field” Free sample and volume discounts

Dental Sleep Education that fits your schedule The Academy of Clinical Sleep Disorder Disciplines is the only organization offering a fully online and on-demand certificate in Dental Sleep Medicine. Study the lectures and course materials at your own pace, then when you are ready, take the exam. A C.DSM certificate from ACSDD provides the necessary medical and dental knowledge to confidently approach physicians and seek insurance reimbursement.

ACSDD.ORG (800) 261-1809

Call 1(800) 261-1809 to Enroll Today The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider at info@acsdd.org or to ADA CERP at www.ada.org/goto/cerp. This program has been submitted for approval by the ACSDD for a maximum of 13 credits as meeting general dental requirements.

PRACTICEmanagement

Let Technology Help You Streamline Medical Billing by Rose Nierman, CEO, Nierman Practice Management

id you know that 90% of claim denials from medical insurance are preventable? Medical billing is perhaps the most vital activity in dental sleep medicine practice. Whether your office outsources medical billing or bills inhouse, technology makes the task much more straightforward and leads to fewer denials. The following are a few suggestions on how to streamline medical billing with modern technology. 1. Adopt an online Dental Sleep Questionnaire. Have patients complete a dedicated sleep questionnaire. Specific forms such as Nierman Practice Management’s Dental Sleep History Intake & Exam save administrative time, paper, and confusion. The data from the questionnaire informs the insurer of medical comorbidities related to obstructive sleep apnea. Without specific data, the claim may be delayed while the insurer is waiting for more information. 2. Electronic claims take precedence over paper claims, so use electronic billing when possible. You may see your claims reimbursed within two weeks, instead of the 30 to 90 days commonly found with paper claims. 3. Implement Secure Electronic Fax. E-fax allows you to supply your narrative reports, sleep studies, and prescriptions

Rose Nierman is a leading expert in cross-coding and medical billing in dentistry. Rose’s mission is to help dentists implement dental sleep medicine and TMD services. A major innovator in narrative and medical billing software, DentalWriter, Rose developed Dental Sleep Medicine and TMD Questionnaire and Exam forms to help establish medical necessity. Nierman Practice Management provides CrossCoding and medical billing seminars along with clinical dental sleep medicine and TMD courses. Contact Nierman Practice Management at contactus@dentalwriter.com or 1-800-879-6468.

52 DSP | Winter 2019

directly to the insurer, saving time and eliminating excess paper. 4. Request Electronic Remittance Advice (ERA’s) – An electronic version of the explanation of benefits (EOB), the ERA provides claim payment information much more quickly than a phone call or waiting on the paper EOB...by snail mail. 5. Use Web Portals to save time on initial eligibility verification and other details. An example: Medicare’s online web portal for providers and suppliers reveals if the patient has had “same or similar equipment” (such as CPAP). 6. Embrace repeatable systems whenever possible. When used correctly, technology can reduce the number of human errors that are possible and take some of the burdens off administrative staff. Consider a program that collects medical and sleep history online, generates custom narrative reports based on your evaluation, and creates completed claims for electronic submission. Establishing a repeatable process for medical billing will increase patient access to care for sleep apnea and TMJ appliances, oral surgeries, and other medically necessary services. Don’t leave money on the table when medical benefits may be available. With proper training, and the use of modern technology, it’s possible to become a well-oiled cross-coding machine. That way your team can focus on what is most important: providing the best possible patient care!

PRODUCTspotlight

Great Lakes Now Offers the Medley Sleep Appliance

reat Lakes Dental Technologies is pleased to offer the Medley Sleep Appliance for patients suffering from sleep apnea and nighttime snoring. The unique Medley appliance features a platform with dual configuration options that can accommodate different advancement mechanisms including: rigid nylon links, elastomeric (EMA) straps, or telescopic Herbst® rod sleeve arms. Medley offers personalized advancement options for ultimate patient comfort without treatment delays or the need for multiple appliances.

“My patients respond well to treatment and are happy that they don’t have to incur additional cost for a new appliance or a delay in treatment.” – Dr. Robert Rogers

54 DSP | Winter 2019

According to Robert Rogers, DMD, DABDSM, and inventor of the Medley, “The Medley Appliance serves the needs of a vast majority of my patients who suffer from sleep apnea and nighttime snoring. I have used this appliance almost exclusively for five years. I am also thrilled to partner with Great Lakes Dental Technologies as the sole laboratory to manufacture my sleep appliances for distribution in the United States and Canada.” This versatile appliance offers three different design applications to treat a majority of patients. The Medley Rod Sleeve utilizes a “pushing” force, and the telescopic Herbst rod

sleeve mechanism offers superior strength and firmer jaw positioning. The Medley Rigid Nylon Links utilizes a mandibular “pulling” force, and the nylon link material provides a more rigid, firmer advancement feel, and won’t deform. The Medley Elastomeric also utilizes a mandibular “pulling” force, but the subtle stretching characteristic of the elastomeric straps allows maximum comfort during advancement, making it ideal for patients with tender joints or loose teeth. To learn more about the Medley Sleep Appliance, contact Great Lakes Dental Technologies at 1-800-828-7626 or visit GreatLakesDentalTech.com. Great Lakes Dental Technologies is an employee-owned company with over 275 employee owners who design, develop, manufacture, and market products for use in the orthodontic, dental, and sleep/airway market. Great Lakes is one of North America’s largest orthodontic laboratories and offers more than 4,000 products and services. Great Lakes is a nationally approved PACE Program Provider for FAGD/ MAGD credit. Great Lakes headquarters is located in Tonawanda, New York, a suburb of Buffalo.

THE MEDLEY SLEEP APPLIANCE

“THE MEDLEY APPLIANCE SERVES THE NEEDS OF A VAST MAJORITY OF MY PATIENTS WHO SUFFER FROM

Three Different Design Applications

SLEEP APNEA

AND NIGHTTIME

THE MEDLEY ROD SLEEVE SLEEP APPLIANCE This application 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

SNORING.” —Robert Rogers DMD, DABDSM Inventor of the Medley

This application, 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 This application utilizes a mandibular “pulling” force. The

SMLP712Rev101519

subtle stretching characteristic of the elastomeric (EMA) straps allows maximum comfort during advancement.

LEARN MORE

Ideal for patients with tender joints or loose teeth.

MedleySleepAppliance.com

* Herbst is a registered trademark of Dentaurum, Inc.

or 800.828.7626

CASEstudy

Rhinomanometry-Measuring Nasal Flowrate to Improve TMJ Function by Steven Olmos, DDS, DABCP, DABCDSM, DABDSM, DAIPM, FAAOP, FAACP, FICCMO, FADI, FIAO

iane a 62-year-old female, BMI 22, unremarkable medical history with the exception of osteopenia was referred to my office for concerns about jaw joint noises and jaw deflection to the right upon opening in September 2018. She states that it is easy to fall asleep, wakes rested, however she wakes twice nightly to urinate. She injured her neck in a motor vehicle accident in 2000. She occasionally has a dull mild ache on the right side of her cervical spine. Her Epworth Sleepiness Scale and David White Nighttime Sleepiness Evaluation were both zero.

Medications: Lipitor-statin drug, Retasis-ophthalmic emulsion for dry eyes, Travatan-2 reduces pressure from glaucoma, Vagifen-estrogen replacement. She drinks less than 4 cups of coffee per day. She does not smoke tobacco. She does not use alcohol and/or sedatives for pain relief and/or sleeping aids. She denies any trouble breathing through her nose. She has had prior orthodontic treatment. Currently using maxillary and mandibular retainers. Clinical exam revealed normal BP 102/75, pulse 81, temperature

Figures 1 and 2: Mallampati Class IV, tongue coated at base and retracts upon opening.

Figure 3: CBCT imaging revealed reduced joint space bilaterally.

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97.5. Palpation revealed mild pain on right anterior temporalis and right medial pterygoid muscles, right posterior TMJ joint space, left rotated cervical vertebra 5, 6, 7. Moderate pain on right lateral TMJ capsule, and right stylomandibular ligament insertion on medial surface of gonial angle of mandible. Mandibular ranges of motion were normal: maximum opening 52 mm, left and right lateral at 10 mm, with Class I dental and skeletal relationships. Mallampati Class IV, tongue coated at base and retracts upon opening. These are findings consistent with airway obstruction, as are nasal obstruction and high Mallampati.1,2,3 Joint vibration analysis (JVA) (BioResearch, Inc., Brown Deer, WI) demonstrates ligament laxity of the left TM joint, (vibrations greater than 20 Hz indicate pathology), Figure 4. JVA is an instrument that measures the hard and soft tissue dynamically as the jaw is moving to discern either health or pathology.4,5,6,7

Figure 4: Joint vibration analysis

CASEstudy CBCT imaging reveals calcified stylohyoid ligament/muscle on the right side. This is evidence of a long-standing movement disorder. The reason why it is unilateral is that the patient has a cant of the mandible up to the right (Figures 5 and 6). CBCT imaging of the nose demonstrates nasal valve compromise, soft tissue hypertrophy of the Vomer (swell body) and inferior turbinates (Figures 7 and 8). Nasal obstruction results in mouth breathing with facial and masticatory muscle dysfunction.

My Diagnosis

Capsulitis of the TM joint (bilateral). Suspected Sleep Breathing Disorder (SBD), with

nasal obstruction. I believe the inflammation and mechanical changes to the joint are secondary to a movement disorder the result of an obstructed airway. Nasal obstruction results in mouth breathing. This fatigues the elevator muscles (temporalis, masseters, medial pterygoids) and the relief to the lactic acid is to contract (clenching). Mouth breathing results in changes to mandibular position and can result in anterior open-bite as referenced in the orthodontic literature (Harvoldâ&#x20AC;&#x2122;s monkeys).8,9 This is due to a weakening of the orbicularis oris muscles and anterior tongue posture. The stretching of the mandible and in turn the TMJ ligaments results in tissue displacement.

Plan

Decompression appliance therapy is needed for the nocturnal forces of sleep bruxism that have produced her craniofacial symptoms. Weekly treatments using the MLS laser (BioResearch, Inc., Brown Deer, WI) to reduce inflammation and shorten stretched TMJ ligaments. While she is undergoing therapy for her orthopedic complaints, she will be referred to a BoardCertified Sleep Physician, and ENT. As I suspect a SBD and know is has nasal obstruction, the decompression appliance will need to maintain a patent airway in all four points of obstruction (Figure 9). Maxillary nighttime therapy is necessary: DDSO (Diamond Digital Sleep Orthotic) is a printed Type 12 nylon appliance with Nasal Dilators and Tongue Pillows. The DDSO is the only appliance that can titrate vertically, protrusively, manage the tongue and the nasal valve simultaneously. The bite registration technique used was the Sibilant phoneme registration, which has been demonstrated to reduce pharyngeal collapse and increase volume of the airway.10 She will be evaluated for

Figures 9-10: 9. Points of obstruction. 10. Removable nasal pillows and bands of different resilience without latex, and vertical pads.

Dr. Steven Olmos has been in private practice for more than 35 years, with the last 30 years devoted to research and treatment of craniofacial pain, temporomandibular disorder (TMD), and sleep-disordered breathing. He obtained his DDS from the University of Southern California School of Dentistry and is Board Certified in both Chronic Pain and Sleep Related Breathing Disorders by the American Board of Crainofacial Pain, The Academy of Integrative Pain Management, American Board of Dental Sleep Medicine, and American Board of Craniofacial Pain and Dental Sleep Medicine. Dr. Olmos is the founder of TMJ & Sleep Therapy Centres International, with over 60 centres in 7 countries dedicated exclusively to the diagnosis and treatment of craniofacial pain and sleep disorders. Figures 5-8

DentalSleepPractice.com

CASEstudy MMI in 10-12 weeks. She will benefit from the following adjunct therapies/ supplementation, MLS cold laser (BioResearch, Inc.), deflame diet, medication regimen, nasal spray, and prolo therapy injections. Her prognosis is good. Nasal pillows or dilators are necessary when the patient has nasal valve compromise or collapse, as Diane’s CBCT revealed. She was directed to use Xlear nasal spray (Xlear, American Fork, UT) before bed for her nasal blockage. Nasal spray is necessary to shrink soft tissue swelling in the nose and increase flowrate. A recent study found a 20% increase in volume (which can have up to a four-fold increase in flowrate) using hyperosmotic saline and Xylitol.11 The appliance was delivered, and the patient was evaluated weekly. MLS laser therapy was performed to decrease inflammation and accelerate healing (can also reduce orthodontic treatment time by increasing tooth movement).12,13,14,15 At four weeks a sleep study was performed. It consisted of three nights utilizing HST (home sleep testing), as ordered by the sleep physician. The results were: Night 1 – AHI 2.5, nadir oxygen desaturation 91%, diagnosis = Hypersomnia. Night 2 – AHI 4.2, nadir oxygen desaturation 90%, diagnosis = Hypersomnia. Night 3 – AHI 1.8, nadir oxygen desaturation 89%. Patients are often told that they do not have apnea with these results; however, that is inaccurate. The patient has upper airway resistance syndrome (UARS). This does not take into account unhealthy meals (high in sugar or saturated fat, low in fiber), that both worsen RDI.16 The patient was treated for 12 weeks of laser treatment and decompression appliance therapy. Re-evaluation diagnostics revealed a reduction of joint pathology (noises) from 38 Hz left and 14.5 Hz right to 5.3 and 4.5 Hz respectively utilizing JVA (Figure 11).

Figure 12

Figure 13

Figure 11

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The patient was asked to quantify reduction of her chief complaints and stated that they had plateaued at 30% reduction of mandibular deflection on speaking and jaw joint noises at 40%. This demonstrates the value of the subjective evaluation of the patient and an objective measurement of the TMJ function, which showed a return to normal function in relation to noises. I explained to Diane that her remaining symptom of jaw deflection was secondary to nasal obstruction (mouth breathing). This is a muscle problem and not a TM joint problem. I demonstrated by spraying her nose and inserting nasal dilators that it corrected the deviation. She needed surgery to improve nasal function and airflow. It is always difficult to know how much of the obstruction we see on CBCT imaging makes a clinical difference in patient symptoms. Rhinomanometry (GM Instruments, BioResearch) measures flowrate as opposed to rhinometry, which measures volume.17 Rhinometry is helpful in discerning

CASEstudy where the most narrow portion of the nasal airway is for triaging treatment options (sprays or surgery).18 Anterior rhinomanometry and acoustic rhinomanometry are probably the most common methods of clinical measurement of airflow.19 An example of proper airflow is shown in Figure 13 showing the contoured line in the green for both left and right valves. Diane’s presurgical readings (1/31/2019) are shown with almost horizontal flow demonstrating severe obstruction (Figure 14). Post nasal surgery (4/11/2019) demonstrates improvement, showing a comparison of left and right flowrates however still below normal levels (Figures 15 and 16). The clinical result was that she was left with a noticeable movement of the mandible to the right upon speaking. Most ENT surgeons perform surgery for the 2, 3, and 4 airway zones identified in the saggital head drawing (nasopharynx, velopharynx, oropharynx). They rarely perform surgery for the first point of entry: the nasal valve. A new surgical technique that is very easy to perform is Vivaer (Aerin Medical). It is an internal recontouring of the nasal valve by radiofrequency and pressure. It can be completed in the ENT office with local anesthetic. Demonstrating that the deviance of her mandible was the result of the nasal valve was demonstrated by nasal dilators (Figures 17 and 18). Video of speech (without and with nasal valve dilation), and the freeze frame of recorded speech with deviation and without using nasal dilation. Note the rotation (yaw) and medial lateral cant (roll). In these two-dimensional pictures it is not possible to demonstrate the third-dimension distortion anterior posterior cant (pitch). Rhinometry and Rhinomanometry were necessary to show the ENT a reason to schedule for revision surgery for the nasal valve and resolve her speaking deviance. Use of the nasal dilators helped connect the measurements with clinical outcome for Diane. She is scheduled for Vivaer procedure.

Figures 17 and 18 1.

3. 4.

6. 7.

8. 9.

10.

11.

12.

13.

Figure 14

14.

15.

16.

17.

18.

19. 20.

Figures 15 and 16

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Barcelo X, Mirapeix RM, Buges J, et al. Oropharyngeal Examination to Predict Sleep Apnea Severity. Arch Otolaryngol Head Neck Surg. 2011;137(10):990-996. Rodrigues MM, Dibbern RS, Kruel Goulart CW. Nasal Obstruction and High Mallampati Score as Risk Factors for Obstructive Sleep Apnea. Braz J Otorhinolaryngol. 2010;76(5):596-9. Atkins M, Taskar V, ClaytonN, Stone P, Woodcock A.Nasal resistance in obstructive sleep apnea. Chest. 1994; 105: 1133-5. Ishigaki S, Bessette RW, Maruyama T. Vibration of the Temporomandibular Joints With Normal Radiographic Imagings: Comparison Between Asymptomatic Volunteers and Symptomatic Patients. Cranio April 1993, Vol. 11, No. 2. S. Sharma1; W. D. McCall1; H. Crow1; Y. Gonzalez-Stucker1 Reliability and Diagnostic Validity of Joint Vibration Analysis. Presentation at 2015 IADR Meeting, Boston, MA USA Based on Masters Thesis of S. Sharma. 1 School of Dental Medicine, State University of New York - SUNY - Buffalo, Buffalo, New York, United States Radke JC, Kull RS. Comparison of TMJ vibration frequencies under different joint conditions. CRANIO 2015 Vol. 33, No 3. Sharma S, Crow HC, Kartha K, McCall Jr WD, Gonzalez YM. Reliability and diagnostic validity of a joint vibration analysis device. BMC Oral Health (2017) 17:56. Harvold E, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359-372. Vargervik K, Miller AJ, ChiericiG, Harvold E, Tomer BS. Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod. 1984;85(2):115124. Singh GD, Olmos S. Use of a sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath 11(4):209-16 · January 2008 Olmos S, Baba J. “Improved Nasal Volume Utilizing Hyperosmotic Saline Xylitol Mixture (Effective Alternative or Adjunct to Decongestants and Antihistamines)”. EC Pulmonology and Respiratory Medicine 8.5 (2019:): 444-452. Enwemeka CS, Parker JC, Dowdy DS, Harkness EE, Sanford LE, Woodruff LD. The efficacy of low-power lasers in tissue repair and pain control: a meta-analysis study. Photome Laser Surg., 2004, Aug;22(4):323-9. Bennett CA, Olmos SR. Treatment of Chronic Craniofacial Pain with Mphi Laser and Orthotic. Energy Health 2014 VOL [13], ISSN 22813268. Bezuur NJ, Hansson TL. The effect of therapeutic laser treatment in patient craniomandibular disorders. J Cranomandib Disorders., 1988, 2: 83-86. Cruz DR, Kohara EK, Ribeiro MS, Wetter Nu. Effects of Low-Intensity Laser Therapy on the Orhtodontic Movement Velocity of Human Teeth: A Preliminary Study. Lasers in Surgery and Medicine 2014 35:117-120. St-Onge MP, Roberts A, Shechter A, Choudhury AR. Fiber and Saturated Fat Are Associated with Sleep Arousals and Slow Wave Sleep. J Clin Sleep Med 2016;12(1):19-24. Demirbas D, Cingi C, Cakli H, Kaya E. Use of rhinomanometry in common rhinologic disorders. Expert Rev Med Devices. 2011 Nov;8(6):769-77. Roithmann R, Cole P, Chapnik J, Shpirer I, Hoffstein V, Zamel N. Acoustic rhinometry in the evaluation of nasal obstruction. Laryngoscope. 1995 Mar;105(3 Pt 1):275-81. Cummings C. Otolaryngology: Head and Neck Surgery. St. Louis, Mo: Mosby Year-Book; 1999. 801-6, 816, 820. Chen I, Lin Y, Hsu J, Liu Y, Wu J, Dai Z. Nasal Airflow Measured by Rhinomanometry Correlates with FeNO in Children with Asthma. PLoS One. 2016; 11(10): e0165440. Published online 2016 Oct 28

PRODUCTspotlight

BeamReaders by Dr. Zubad Newaz

our BeamReaders radiology report will help you identify all anatomic features located between the external nasal valve and trachea that are contributing to an increase in airway resistance. This includes assessing the airway dimensions, the skeletal framework that bounds the airway, facial growth patterns and identifying airway encroachments.

A patient with sleep related breathing disorder shows the following contributing anatomic features: MCA small measuring 62 mm2, recessive maxilla (SNA = 76 degrees), recessive mandible (SNB – 72 degrees), acute skull base angle (BaSN = 124 degrees), bilateral degenerative joint disease, dolichofacial and long soft palate.

Cone Beam CT has a role in the anatomic assessment of the airway and the structures that support the airway. BeamReaders’ team of Oral and Maxillofacial Radiologists focus on key anatomical areas and functional interrelationships when evaluating a CBCT scan for an airway focused radiology report. The following is a brief outline of the factors involved in accessing the influencers on a patient’s airway resistance. Airway Dimensions: Airway analysis in a CBCT involves mapping and measurement of the airway, including determining the most constricted area [MCA], volume and linear distances. The MCA can be an indication of the level of risk of SRBD and identified as a site of increased resistance. The airway analysis results can be influenced by the head, spine and tongue posture. This underlies the importance of having a defined patient setup protocol (for best practices see our short video: https://info.beamreaders.com/3Dsleep) Skeletal Framework: The airway is framed by the skull base, cervical spine, jaws, nasal cavity and hyoid bone. The tongue, soft palate, turbinates, epiglottis and airway lumen have to fit within the skeletal framework. Contraction of the skeletal framework diminishes the potential space for the airway lumen. Facial Growth Pattern: Normal facial growth is characterized by a counterclockwise rotation of the mandible thus projecting men-

Zubad Newaz, DDS, is a graduate of the University of Michigan School of Dentistry, and went on to complete residencies in both Oral & Maxillofacial Radiology and Orthodontics at the University of Florida and NYU-Langone Hospitals, respectively. He has been a member of the BeamReaders team since 2016 and is currently engaged in airway-focused practice of both specialties, based out of Florida and New York City.

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ton and the skeletal attachments for the genioglossus and geniohyoid muscles anteriorly. A dolichofacial growth pattern rotates the mandible and menton in a clockwise direction. A clockwise rotation of the mandible allows the hyoid bone to descend and tongue to posterinferiorly reposition. A dolichofacial growth pattern is often associated with reduced condylar size and growth anomalies which can influence the airway. Airway Encroachments: The most common airway encroachments include hyperplasia of the lymphoid tissues; adenoids, lingual tonsils and lateral pharyngeal tonsils. Tongue, turbinate and soft palate sizes are assessed. The airway spaces are screened for benign and malignant neoplastic formations. The nasal fossae and paranasal sinuses are evaluated for inflammatory changes. The encroachment on the airway by any of these can significantly alter airway resistance. A BeamReaders radiology report evaluates all of these anatomical areas and combines the various anatomic situations into a cohesive diagnostic impression. Allowing a BeamReaders radiologist virtually onto your team reduces liability, improves understanding of all the factors involved, and provides a great communication tool with the patient and others involved in the patient’s care. The use of CBCT in your dental sleep practice should go far beyond just determining the MCA. A BeamReaders radiology report can be one of your primary tools to help in the assessment of the multiple factors that can contribute to airway resistance. The report provides a great platform to easily educate your patient, engage other treatment providers, increase your confidence in your treatment planning, and reduce liability associated with the large volume scan. These benefits will invariably help improve outcomes and efficiency, helping to grow the reputation and productivity of any dental sleep practice. About BeamReaders: BeamReaders is a team of more than 50 Oral and Maxillofacial Radiologists working to help you succeed in your dental sleep practice. Submit your first case for free today by registering at www. BeamReaders.com and using the registration code: BRSLEEP

PRODUCTspotlight

Hybrid Practice Leads to Hybrid Therapies by Joseph Zelk, DNP, FNP, BC, CBSM, DBSM

n nearly 20 years of practice in sleep disorders, I’ve seen transitions from PSG to HSAT, from all-CPAP to more inclusion of OA therapy for patients of all levels of diagnosis. But now, I believe the next evolution in OSA treatments will be hybridized practice and hybridized therapies. In 2005, I wrote about combining different sleep specialists together in one location and coined the label “hybrid therapies.”1 Soon afterwards, I had the opportunity to form a hybrid practice model with Richard Moore, DDS, ABDSM, as dental director – I became the medical director of Sleep Medicine Group in Portland, OR and Vancouver, WA. The hybrid practice model was successful due to our efforts lobbying insurance companies to recognize home sleep testing (HST) for OSA. To thrive, we also found it necessary to deliver care in a medically-managed oral appliance therapy protocol for OSA.

Oral appliance sleep study (left) compared to the oral appliance with Bongo Rx sleep study (right)

Joseph Zelk, DNP, FNP, BC, CBSM, DBSM, is a sleep specialist who holds a board certification by the ABSM and BBSM. Dr. Zelk is a nationally known speaker on sleep disorders and cardiovascular disease, co-inventor of several SDB-related medical devices, and has been an invited expert for sleep disorders-related topics for several publications and conferences. He has completed a residency with a focus on oral appliance therapies for the treatment of OSA.

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Local success with this model led to a national campaign to train dentists in oral appliance therapy and gave us access to other sleep specialists to introduce them to hybridized therapies such as oral appliance/CPAP, oral appliance/upper airway surgery, oral appliance/nasal dilation, and oral appliance/ side sleep therapy or weight loss management. After over 15,000 oral appliance patients and many hundreds of Hybrid Positive Airway Pressure (HPAP) patients, we are convinced the foundation of airway support is to stabilize the mandible and add treatments to achieve the best outcomes, with optimum adherence to therapy as a major outcome goal. I recently have had several positive patient outcomes combining Bongo Rx and oral appliance therapy. Notably was one very severe OSA patient (96/hr AHI) with suboptimal oral appliance treatment after he failed CPAP. Follow up testing showed he still had severe OSA with OA alone (61/hr AHI) but needed CDL clearance. Typically we would attempt HPAP (oral appliance with CPAP), but that would take months of time that he did not possess. We chose a trial of HybridEPAP therapy, which reduced his 96 AHI to 2.5. Best of all, he tolerated wearing the EPAP (Bongo Rx) with his oral appliance, unlike his previous CPAP experience. When compared head-to-head with PAP, OAT has been found to be as effective in many parameters except AHI reduction.2 With new therapies coming to market like the genioglossal nerve stimulator, (cNEP), novel TRDs, oral negative pressure, soft palate stiffening procedures, myofunctional therapy, maxillary development platforms, hybrid-EPAP and possibly future hybrid autoEPAP therapies, I look forward to a sleep community brought together by the hybrid practice treatment of OSA. 1. 2.

Zelk J. Taking a bite out of SDB. Sleep Medicine Reviews. 2005;8: 25-26. Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, et al. Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. AJ AM J Respir Crit Care med. 2013;187(8):879-887.

Introducing Hybrid Therapy The Next Evolution in OSA Treatment

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LEGALledger

Telemedicine and the Provision of Dental Sleep Medicine by Jayme R. Matchinski, Esq.

he expansion of telemedicine is changing the landscape of providing Dental Sleep Medicine and oral appliances. This article will address key issues and regulations dentists and dental practices should consider and navigate in order to avoid potential pitfalls and liability. Dentists and patients are relying more heavily on telemedicine for the provision of Dental Sleep Medicine. Advances in technology and health care delivery systems such as telemedicine are improving patient access and the quality of health care. The use of cone beam technology and 3D images is also changing how patient care is provided by dentists and dental practices. As the use of telemedicine continues to expand, dentists and third-party payors need to ensure regulatory compliance and navigate the related risks in implementing telemedicine practices and programs.

Telemedicine Laws and Regulations Proposed laws and rules related to telemedicine will continue to expand coverage, and many national insurance companies have

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implemented online medicine by adding access to approved telemedicine networks for their insureds. The provision of online medicine and related telemedicine services by dentists, for the most part, is subject to the same regulatory and liability issues as “brick and mortar” providers. Issues regarding acrossstate-line care, HIPAA violations, kickbacks, and inappropriate prescribing for drugs, medical devices, and durable medical equipment (DME) are all key considerations for dentists who decide to provide telemedicine services. The terms telehealth and telemedicine are sometimes used interchangeably. The Health Resources & Services Administration (HRSA) of the U.S. Department of Health and Human Services defines telehealth as: “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration.” (http:// www.hrsa.gov/rural-health/telehealth/index-html). The HRSA distinguishes telehealth from telemedicine in its scope. According the HRSA, telemedicine describes remote clinical services such as diagnosis and monitoring,

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LEGALledger while telehealth includes preventive, promotive, and curative delivery. (http://www.hrsa. gov/rural-health/telehealth/index-html). Most state regulations use and reference “telemedicine” to define the scope of practice, licensure, and reimbursement for remote clinical services, including diagnosis and monitoring. Dentists entering into agreements for the provision of online health care should be aware of the regulatory and liability risks associated with telemedicine to address the patient consent, fraud and abuse, licensing and HIPAA hurdles. Key issues that dentists should consider when entering into agreements for telemedicine and the provision of Dental Sleep Medicine include: ❍❍ What are the appropriate billing codes? ❍❍ Did the dentist, as the provider of Dental Sleep Medicine and the oral appliance, satisfy the applicable regulatory requirements? ❍❍ Were the applicable geographic location requirements met? ❍❍ Was the patient at the appropriate originating site? ❍❍ Did the technology meet the audio and visual requirements? ❍❍ Subsequent to the initial 90 day period following the oral appliance delivery, will the payor reimburse the dentist who conducts a telemedicine E&M consult? ❍❍ Were any non-covered services billed?

State Telemedicine Regulations Telemedicine regulations vary from state to state. Many “parity” states have updated or adopted new state law to require private insurers to cover services provided through telemedicine if the same services provided in-person are covered and reimbursed by the insurance

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

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companies. State laws governing telemedicine will continue to expand and evolve as technology impacts access to health care and the provision of patient care. Currently, there are no uniform telemedicine regulations other than the Medicare and Medicaid coverage guidelines and regulations. Statutes or regulations have been promulgated and enforced on a state, not federal, level due to scope of licensure and reimbursement considerations. Each state must regulate telehealth issues related to: establishing the physician/patient relationship, patient consent and disclosures, scope of practice, licensure, recordkeeping and information access, clinical standards, payment practices, coordination of care, and prescription standards.

Medicare Coverage for Telehealth has Expanded but There Are Limits Before 2015, Medicare did not pay separately for telehealth, and telehealth and telemedicine services were bundled into “evaluation and management” codes. However, in 2015, the Center for Medicare & Medicaid Services (CMS) added further telehealth coverage. CMS has added seven telehealth billing codes, including codes for psychotherapy, prolonged office visits and annual wellness visits conducted electronically. CMS also began paying for remote patient monitoring for chronic conditions. CMS has reimbursed providers for remote patient face-to-face services via live video conferencing requirements when the eligible beneficiary in the originating site is located outside of a Metropolitan Statistical Area (MSA) for eligible medical services, and the telehealth is provided by eligible providers and by an eligible facility. If these requirements are met, the practitioner delivering services will be reimbursed for medical services in the same amount as the current fee schedule and nonmetro facility eligible for facility fee. However, Medicare reimbursement for telehealth continues to be available only at clinical sites in rural areas. CMS restricts telehealth services to beneficiaries that live in counties outside of a MSA and within a health professional shortage area (HPSA) as designated by the federal government. Medicare does not reimburse for remote non-face-to-face services, as such services are

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LEGALledger not considered to be telehealth by CMS and are covered as on-site services. An example of remote non-face-to-face services is an interpretation of an electrocardiogram that has been transmitted via telephone.

Telemedicine Providers should Be Aware of Medicaid Payments Review Medicaid programs pay for telemedicine, telehealth, and telemonitoring services delivered through a range of interactive video, audio or data transmission (telecommunications).

Rapid changes in technology and health care delivery systems will allow dentists and patients to increase their use of telemedicine.

The Medicaid Services Delivered Using Telecommunication Systems project was initiated by the Office of Inspector General (OIG) and included in the OIG’s November 2017 Work Plan update. The OIG notes the “significant increase in [Medicaid] claims for telehealth, telemedicine and telemonitoring services” and indicates that the OIG expects the trend to continue. Compliance with the Medicaid requirements that apply to telehealth differs from state to state. The coverage, coding, and documentation rules are not necessarily easy to find. Most telehealth requirements are found in policy manuals and transmittals rather than in regulations. Medicaid providers should continue to monitor the OIG’s Medicaid Services Delivered Using Telecommunication Systems for updates. The OIG is expected to issue a report on the project in 2019 to provide further guidance on Medicaid requirements and reimbursement for telehealth providers.

Exploring the Range of Telemedicine Models and Provider Arrangements There are many business models and provider arrangements for the provision of telemedicine. Given the regulatory climate and increasing use of telemedicine by dentists and patients, these business models and provider arrangements are continuing to change.

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Dentists should think about how telemedicine is provided pursuant to the model and provider arrangements to ensure regulatory compliance, proper documentation, and the ability to receive reimbursement for the provision of telemedicine. The following are a few examples of telemedicine models and provider arrangements utilized by dentists and patients: • Online patient access/portals/technical support – A sleep disorder center provides patients with online access to view results from the polysomnography (sleep study) and offers patients options regarding the treatment of sleep disorders, including Dental Sleep Medicine and oral appliances. • eHealth, mHealth, and medical apps – Self-tracking apps for diagnostics, care support, and monitoring that may include weight loss, smoking cessation, medication compliance, and oral appliance compliance. Dentists should carefully consider and monitor the structure of business models and provider arrangements so that there is proper documentation of the provision of the telemedicine and receipt of the correct reimbursement. Dentists and dental practices should consider the following issues which are related to the provision of telemedicine: ❍❍ Business terms and transactional considerations, including compensation; ❍❍ Intellectual Property; ❍❍ FDA complianace; ❍❍ Data Access; ❍❍ Scope of Practice and Licensure; ❍❍ Patient Privacy and Information Security; ❍❍ Fraud and Abuse Concerns; ❍❍ Cybersecurity Insurance; ❍❍ Reimbursement; and ❍❍ Regulatory Compliance, including HIPAA and State Privacy Regulations. Dentists who provide telemedicine are subject to licensure regulations in the state(s) where the dentists are located and licensed and the state in which the patient is physically located at the time of the consult. Depending upon the technology platform and the professional services being provided, the provision of telemedicine could result in a dentist practicing Dental Sleep Medicine in all fifty states. Regarding

LEGALledger dental practice licensure and related rules, it is generally accepted that the law that governs the consult is the law from the state where the patient is located at the time of the consult. Some states specifically address these issues in the state law or related guidance, while some states indirectly address the practice rules by including diagnosing and rendering treatment through electronic or other means as part of the practice of medicine; other states are silent. Some states allow an unlicensed dentist to practice dentistry in peer-to-peer consultation with a dentist licensed in the state, and the local dentist who is licensed in the state retains the ultimate authority over treatment and diagnosis. Other exceptions for unlicensed dentists include: bordering state licensure, endorsement, special telemedicine licenses, and follow-up care. Given scope of practice, licensure, state

board disciplinary actions, and malpractice considerations, dentists should carefully navigate the provision of professional services through telemedicine and ensure regulatory compliance to avoid licensure and state board disciplinary actions. As telemedicine continues to grow, dentists and patients will need to navigate telemedicine requirements for licensing, scope of practice and reimbursement. Rapid changes in technology, Dental Sleep Medicine, and health care delivery systems will continue to allow dentists, patients, and other health care providers to increase their use of telemedicine. While there are many opportunities for dentists to implement and use telemedicine, dentists must continue to closely monitor the changing regulatory landscape to ensure compliance, receive reimbursement, and avoid potential pitfalls and exposure to liability.

Delta Sleep International Presents

Business Trends in Dental Sleep Medicine

Dr. Jonathan Lown

Dr. Arthur Feigenbaum

Dr. Kent Smith

Scott Craig

Dr. David Hatcher

Dr. Dan Tache

Cindy White

Jayme Matchinski

Dr. Michael Goldberg

Elias Kalantzis

Dr. Todd Morgan

Dr. Steven Lamberg

March 27-28, 2020 Aria Resort and Casino | Las Vegas, NV

Don’t Miss this Year’s Roundtables

Billing Roundtable with Jeff Burton (Lyon Dental), Lesia Crawford (GoGo Billing), Randy Curan (Pristine Medical Billing), and Megan Cheever (Brady Billing) Industry Leaders’ Roundtable with Len Liptak (ProSomnus Sleep Technologies), David “Kim“ Solomon (Panthera Dental), David Walton (Respire Medical), Lewis Myers (SomnoMed), and Patrick Tessier (Airway Management)

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