Dental Sleep Practice Winter 2020

Apples to Aardvarks

Comparing OAT & PAP Monitoring

by Suzanne Mericle, DMD, and Jeff Wyscarver, RPSGT

Innovation at Arm’s Length

by Barry Chase, DDS

Challenging the Status Quo

by Erin Elliott, DDS

WINTER 2020 | dentalsleeppractice.com PLUS

Continuing Education

ACEs, Integrative Medicine, and the Mind Body Connection Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Sunita Merriman, DDS

PATIENT SCREENING l BITE REGISTRATION l ORAL APPLIANCE SELECTION / FABRICATION

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INTRODUCTION

Please Help!

M

y Mom was rushed to the emergency room on her 63rd birthday.

From there, she was transferred to the ICU for several days. This was during a spike in COVID numbers that elicited warnings to avoid non-life-threatening visits to the hospital. This was life-threatening.

And an emergency.

My Dad called me with the news.

Shocked but unsurprised due to my Mom’s indulgences, I asked what happened. He told me that during a routine visit, her PCP noted that my Mom’s O2 saturation was 74%. I’d previously urged my Mom to have a sleep test an incalculable number of times. She’d shriek, “If it’s a big deal, then a doctor would say something to me about it.” The doctor did say something this time. She said my Mom needed to be transported to the hospital via an ambulance. My Dad couldn’t drive her. It was too urgent.

At the hospital, they administered pulmonary function tests, a CT scan, and numerous other lab tests. Eventually they ordered a home sleep test, too. Guess what? COPD and (cue Final Jeopardy theme music) OSA. We discussed what the next steps would likely be – CPAP, supplemental oxygen, physical therapy – when my Dad quizzically asked, “how do you know all this stuff?” I told him that it’s related to my work to which he chortled, “I thought you were a dental assistant or something like that.”

Fortunately, this event served as the impetus for my parents quitting smoking after more than 45 years, making positive dietary shifts, and getting started with OSA treatment. By “getting started with OSA treatment” what I really mean is struggling with CPAP with little medical guidance and almost no oversight. The frustration and failure my parents feel is palpable.

Note that I said “they.” That’s because I accompanied my Dad to his PCP appointment a few weeks after my Mom was discharged from the hospital. My Dad is a 65-year-old male with a history of smoking and an “I’m enjoying my retirement” happy hour schedule. There, I asked the doctor if he would order a sleep test. He confessed

to not knowing much about sleep apnea.

He asked if my Dad snored or if anyone witnessed apneas. I told the doctor that when visiting my parents, it’s virtually impossible to sleep in their house due to Jason Tierney the ground-quaking snoring punctuated by the staccato horror movie soundtrack that’s actually my Dad gasping for air – trying to stay alive. Trying not to die.

Now, they both struggle with CPAP. They feel that no one is explaining things to them.

Hoses and other supplies are sporadically shipped to their home with no directions or explanations. I have provided them with scripts of questions to ask the medical staff.

My Mom and Dad feel like they’re being If it’s a big deal, ignored or cast aside by the medical profesthen a doctor would sion. At the same time, they’re reluctant to listen to me while they place deep trust in the say something to words of a doctor – the doctor is an authority. me about it.

They think I’m still a naïve, know-nothing kid wearing Underoos and riding skateboards. I keep telling them I quit riding skateboards when I was 15.

My parents visit the dentist at least twice per year. No one there said anything to them about OSA. And they don’t listen to me. But they would listen to you.

Screen your patients. Don’t make assumptions. Communicate. Someone’s parents need you. Please help them. Please. p.s. Kudos to the American Academy of Dental Sleep Medicine for their recent position paper on home sleep testing. This stance is certain to improve access to care and likely to save lives. Thank you, AADSM. Dental Sleep Practice subscribers are able to earn 2 hours of AGD PACE CE in this issue by completing questions about the article “ACEs, Integrative Medicine, and the Mind Body Connection” which starts on page 38. Sponsored by MedMark, LLC, and CE Zoom, LLC.

DentalSleepPractice.com

1

CONTENTS

10

Cover Story

Challenging the Status Quo

by Erin Elliott, DDS Which of your patients will benefit from OAT? What if you knew their optimal treatment position with no titration? Dr. Erin Elliott tells us how she sees the future every day in her practice.

8

Adjunctive Therapy

Weeding Out the Truth: CBD and Sleep

by Kent Smith, DDS, D.ABDSM CBD is for sale on every street corner.

What is it and how does it affect sleep?

14

Bigger Picture

Apples to Aardvarks: Comparing OAT & PAP Monitoring

by Suzanne Mericle, DMD, and Jeff Wyscarver, RPSGT OAT isn’t on the same level of PAP when it comes to compliance and effectiveness monitoring. What if you could change that tonight?

34 2 DSP | Winter 2020

Continuing Education

38

ACEs, Integrative Medicine, and the Mind Body Connection

by Sunita Merriman, DDS How can childhood trauma affect sleep quality and disordered breathing? What role can dentistry play in identifying these issues? Earn CE credits while learning how integrative medicine may improve OAT compliance and insomnia.

2 CE CREDITS

Product Spotlight

Innovation at Arm’s Length by Barry Chase, DDS The Respire Pink AT represents a seismic shift to the design and functionality of Herbst appliances. Is this your next go-to OAT?

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—Dr. Kent Smith, DDS, D.ABDSM, D.ASBA

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

—Dr. Brandon Hedgecock, DDS, D.ABDSM, D.ASBA

“ProSomnus precision engineered devices provide my patients with consistent results.

ProSomnus devices are smaller, more comfortable and less porous.”

—Dr. Srujal H. Shah, DDS, D.ABDSM

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CONTENTS

6

Publisher’s Perspective

Looking Forward to 2021!

by Lisa Moler, Founder/CEO, MedMark Media

17 Product Spotlight

35 Clinical Focus Breathing Dysfunction and Head Posture

by Theodore R Belfor, DDS, and Michal Niedzielski, PT, PRC

by Mark T. Murphy, DDS, D.ABDSM

Whether it’s from staring at your phone to hunkering over patients, forward head posture may result in pain and breathing disorders.

DSM isn’t innovating at a rapid rate. That’s about to change. Find out how patients, practices, and the profession will benefit.

46 Laser Focus

No More Porridge

18 Expert View

In Your Own Words What makes or breaks a dental sleep practice? Some of the most successful DSM billing companies share their observations.

22 Practice Management

LightScalpel Functional Frenectomies and Frenuloplasties

by Peter Vitruk, PhD, MInstP, CPhys What treatment has been shown to improve quality of life by 87%? Get laserfocused on taking your practice to the next level.

by Rose Nierman

50 Product Spotlight

New code changes are coming, and they will have a direct impact on your practice.

by Samuel E. Cress, DDS

2021 Office Visit Code Changes

25 In the Lab

Laser Sintering New Life into Your Sleep Appliances How appliances are fabricated impact the quality, predictability, and durability.

Laser-sintered Herbst devices give you versatility, too.

28 Communication

Coffee is for Closers: Get Out of Your Own Way

by Michael Cowen Who delivers the clinical and financial treatment plans makes a difference for case acceptance.

30 Billing Blocks

4 Axioms for Medical Insurance Success

by Randy Curran and Kyle Curran What 4 truths are inescapable and selfevident in the world of medical billing for OAT?

4 DSP | Winter 2020

Seeing is Believing

If a picture is worth a thousand words, what is a crystal clear view of the airway, sinuses, and TMJ worth? Dr. Sam Cress says “Axeos” translates to “priceless.”

52 Team Focus

Less Calculus – More Sleep

by Gina Pepitone-Mattiello, RDH Gina shares her journey from hygiene checks to appliance checks; a day in the life of a sleep hygienist.

Winter 2020 Publisher | Lisa Moler lmoler@medmarkmedia.com Editor in Chief | Jason Tierney jason@medmarkmedia.com Managing Editor | Lou Shuman, DMD, CAGS lou@medmarkmedia.com Editorial Advisors Jagdeep Bijwadia, MD Randy Clare Scott Craig Randy Curran Barry Glassman, DMD Elias Kalantzis Steve Lamberg, DDS, D.ABDSM Mayoor Patel, DDS, MS, RPSGT, D.ABDSM Mark Murphy, DDS John Viviano, DDS

Director of Operations Don Gardner | don@medmarkmedia.com Manager – Client Services/Sales Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury | amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius | emedia@medmarkmedia.com Social Media & PR Manager April Gutierrez | medmarkmedia@medmarkmedia.com

54 Product Spotlight

Front Office Administrator Melissa Minnick | melissa@medmarkmedia.com

Treating Severe OSA – Versatility is Key

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496

by Steven Olmos, DDS, D.ABDSM Severe OSA – hybrid therapy should be in your armamentarium. See how to make it a reality.

56 Sleep Humor

...The Lighter Side of Sleep Apnea

www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $149 | 3 years (12 issues) $399 ©MedMark, LLC 2020. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Dental Sleep Practice magazine or the publisher.

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PUBLISHER’Sperspective

Looking Forward to 2021!

T

hrough all of the challenges and changes of 2020, I look forward to 2021 as a year of renewal and rejuvenation. 2020 changed our perspectives on patient care and the way we run our businesses. Sanitizing and masking have become part of daily routines, and new methods of communicating with patients and sharing information with colleagues have brought new efficiencies to dental practices.

Lisa Moler Founder/CEO, MedMark Media

2020 also has taught us that managing our offices efficiently can navigate us through hard times and make the good times even better. This year, dentists discovered that teledentistry can keep them clinically connected with patients as well as keeping information flowing. The American TeleDentistry Association notes that teledentistry can: • Improve dental hygiene of patients • Reduce the cost of care and increase efficiency through reduced travel times, shared professional staffing, and fewer in-person appointments • Be an innovative solution for the mainstream healthcare industry • Improve access to care for patients • Reduce the amount of time patients need to spend away from their offices • Make in-office appointment times more accessible • Make in-office appointment times more accessible to patients who really need them In addition, PPE and aerosol containment policies and other safety precautions will allow you to make future plans to expand your skills and techniques.

Dental Sleep Practice continues to be a trusted source for introspection, invention, implementation, and innovation for your dental practice. Your strength and dedica-

tion to your craft and your teams is truly inspirational.

In this issue’s CE, “ACEs, Integrative Medicine, and the Mind Body Connection”

by Dr. Sunita Merriman, discusses how adverse child experiences can negatively impact treatment for sleep deficiency and sleep disorders in adults. The mind-body connection can present a severe challenge to successfully treating patients if clinicians do not recognize that their impact on treatment outcomes is crucial to providing comprehensive, integrative care. In our cover story, “Challenging the Status Quo,” Dr. Erin Elliott discusses how technology can provide powerful tools in involving patients in the discovery and treatment of their OSA. In “Apples to Aardvarks,” Dr. Suzanne Mericle and Jeff Wyscarver write about Dental Remote Patient Monitoring (DRPM) for better treatment efficacy, to actively engage patients in their treatment, and gain more physician referrals.

This is our last issue for this year, and I think I am joined by all of you in saying that 2021 can’t get here fast enough! We look forward to starting the next year with healing, hope, and vision for a profitable future. As I have said before, stay positive, stay focused, and stay with us as you have over the years. We appreciate and value you, and invite you to contact us regarding submitting articles in 2021.

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

6 DSP | Winter 2020

ADJUNCTIVEcare

by Kent Smith, DDS, D.ABDSM

Y

ou’ve seen it in nail salons and boutique stores. Heck, even gas stations are selling it. What’s the hoopla? Much has been written about cannabidiol, better known as “CBD,” and the majority of it has been offered in the forms of anecdotal evidence, conjecture, attempts to sell a specific product, or some combination of these. I won’t do much better with this article but will try to make the connection between CBD – wait, let’s say the “cannabis plant,” a much broader term – and sleep. Much of our information to date has been found by accident, but let’s start at the beginning.

…(with) clinical endocannabinoid deficiency (CED), we see more anxiety, migraines, IBS and yes, insomnia.

8 DSP | Winter 2020

The cannabis plant, containing over one hundred cannabinoids, has been around for thousands of years, so it wasn’t invented to give you a high or raise Cheetos’ stock. From this magical plant comes hemp and THC. The numerous products on the unregulated and unrestrained free market include various ratios of these two. An increase in the THC percentage provides a more psychoactive result; as the percentage of hemp increases, we see more health benefits. What’s the best ratio? Well, that depends on your needs, which largely depend on the stability of your own endocannabinoid system.

When we are in homeostasis, we have a healthy endocannabinoid system. Our emotional level is good, our digestive system is functioning properly, and we sleep well. If we have a clinical endocannabinoid deficiency (CED), we see more anxiety, migraines, IBS and yes, insomnia. This is where

the phytocannabinoids, those coming from the cannabis plant, are helpful.

In my sleep practice, I am often frustrated with my inability to “fix” every patient’s sleep problem. You have three happy patients on a Monday, then Susan Phillips comes in at 3:30 to go over a titration study and you get her AHI from 22 down to 3 – but she says she feels no better. You’ve all been there. I love the numbers and objective data, but treating symptoms has always been my primary focus, so when something becomes available that could help, I do my due diligence.

When CBD became legal to grow and sell through the Farm Bill in December of 2018, I decided to take a look.

I soon learned that since CBD is not regulated by the FDA. It has become the wild, wild west for CBD manufacturers, and there is no shortage that have cropped up. Independent studies have shown that some CBD bottles tested have not a drop of CBD. So, how do you first decide what brand to use?1 My suggestion is to look for the following in that bottle on the gas station counter or the one your neighbor is trying to sell you: 1. Organically grown – Most will say this, and it is likely true, but it’s particularly important as the hemp plant is excellent at extracting everything from the soil, good or bad.

2. Full spectrum – Any product that is not labeled this way likely has not used all 480 compounds of the plant.

The entourage effect of a product is key to effectively treating the specific

ADJUNCTIVEcare endocannabinoid deficiency in the patient.

3. Water soluble – As we are made of about 60% water, our ability to uptake and use any oil we ingest depends on its ability to dissolve into water. You can test this with your CBD oil by dropping 4-5 drops into a glass of water. If the drops bead up on top, it’s not water soluble and it takes a much larger quantity to produce the same results.

4. Certified by the U.S. Hemp Authority – The bottle should be labeled this way, but you can also find a full list at https://ushempauthority.org/. They have vetted these companies using strict regulatory standards and testing by independent third parties to ensure that what the company says is in the bottle truly is.

5. QR Code – Ideally, the bottle should have a code that allows you to investigate the company yourself by taking you to an independent third-party testing facility’s site. It will detail exactly what is in the batch that made that bottle. This is specifically important when you need to ensure the amount of THC in the bottle is less than .3%, which is the legal limit in most states.

Now that you’ve chosen your CBD oil, let’s discuss how it can help sleep.

1. Anxiety – In one noteworthy study of 72 adults, 47 of them identified anxiety as a chief complaint and 25 with sleep as a chief complaint. Anxiety scores improved in 79.2%; Sleep scores improved in 66.7%.2 2. Sleep stability – Endocannabinoid signaling through the CB1 receptor is necessary for NREM stability. With insomnia victims, CBD helps the endocannabinoid system work properly so that it can effectively modulate sleep cycles.3 3. Pain relief – The only legitimate studies have been in rats, but we know that CBD prohibits the body from absorbing anandamide which is a compound we produce to regulate pain.

An increase in the amount of anandamide in the blood stream may reduce the amount of pain the patient feels, thus leading to better sleep.

If you could improve homeostasis in your patients and reduce their anxiety, pain, and insomnia, would your patients have healthier sleep and even appreciate your efforts to treat more than their snoring? That was rhetorical.

In our office, we use one specific brand, and we have some of their promotional material on shelves in our operatories. I venture to say that it would take extreme effort to find a patient who had not heard of CBD. They see it and begin asking questions. I can go into as little or as much detail as they want, but they know we are not pushing anything – just offering a potential answer for their sleep struggles. An important point that is not well known – CBD has an excitatory component to it, so it should not be taken at bedtime. I suggest a regimen of ½ ml in the morning and again at dinnertime, but never too close to bedtime.

Sometimes we offer our CBD oil at no charge for the patients struggling to pay for their sleep appliance, but most pay for it. A word of caution – some credit card companies will not allow you to charge for CBD using their systems, and you could get your hand slapped if it’s on your website. Sell it on a cash basis or just create a handout that tells them what to look for in a good CBD oil.

You don’t have to provide it in your office, but you owe it to your patients to have a working knowledge of how it can help their sleep.

1.

2.

3.

“Penn Study Shows Nearly 70 Percent of Cannabidiol Extracts Sold Online Are Mislabeled – PR News.” Penn Medicine News News Release, Penn Medicine News, 7 Nov. 2017, www.pennmedicine.org/news/news-releases/2017/november/penn-study-shows-nearly-70-percent-of-cannabidiol-extracts-sold-online-are-mislabeled.

Shannon, Scott, et al. “Cannabidiol in Anxiety and Sleep: A Large Case Series.” National Institutes of Health, The Permanente Journal, 7 Jan. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6326553/.

Pava, Matthew J, et al. “Endocannabinoid Signaling Regulates Sleep Stability.” PloS One, Public Library of Science, 31 Mar. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4816426/.

Kent Smith, DDS, D.ABDSM, is the founding director of Sleep Dallas, a dental sleep medicine practice serving the Dallas-Fort Worth metroplex. Smith is president of the American Sleep and Breathing Academy, a Diplomate of the American Board of Dental Sleep Medicine, and is on the advisory committee of the Australasian Academy of Dental Sleep Medicine. In addition to running his practice, Smith is the founder and primary facilitator of 21st Century Sleep Seminars, a series of training events that prepares dental professionals to incorporate dental sleep medicine into their practices. Smith has also created curriculum for a course focused on recognizing and treating sleep breathing disorders at the Las Vegas Institute of Advanced Clinical Studies.

DentalSleepPractice.com

9

COVERstory

Challenging

10 DSP | Winter 2020

COVERstory

the

Status Quo

by Erin Elliott, DDS

S

leep medicine is one of the fastest growing areas of general dentistry.

An increasing number of practices are now focusing on patients’ overall health in addition to their dental health and hygiene. I love sleep. Whether it’s dental sleep medicine (DSM) or actually catching some ZZZs, I cherish it. Anyone that follows my social media knows this because my husband, Tom often posts pictures of me dozing. I got involved in DSM in 2008 when I saw that there was a sleep physician speaking at our annual Idaho State Dental Association meeting. Once I discovered dentists could be part of a patient’s journey to a better night’s sleep and improved overall health, I was “all in.”

One of the most common sleep disorders dentists treat is obstructive sleep apnea (OSA).1 OSA affects quality of life and may increase the risk of high blood pressure, heart disease, and diabetes if left untreated.2 It would be an exercise in futility to argue that any other type of comprehensive dental treatment is as important as treating OSA. However, it isn’t easy to incorporate sleep medicine into a general dental practice. Screening for potential airway issues, reimbursement, and uncertainty in predicting which patients will respond to oral appliances are very real challenges. Additionally, for many patients there is a striking disconnect between their lack of sleep and pressing health problems. They don’t see the value of medical intervention for what they believe to be a minor nuisance – a slightly annoying snoring problem.

To successfully integrate sleep medicine with general dentistry, we must empower OSA patients in their own care. Instead of telling them what they need, we should involve them in the discovery of their condition and ways to treat it.

A Complete Solution for Evaluating OSA

As dental healthcare providers, we stare at patients’ airways all day. Our clinical experience, coupled with our investment in the right diagnostic tools, puts us in

prime position to identify undiagnosed OSA patients through screening. When evaluating a patient for potential sleep apnea, we utilize cone beam computed tomography (CBCT) to produce a high-quality 3D image of the patient’s airway. Even if research hasn’t shown a connection between the volume of an awake, upright airway and a sleeping, horizontal airway, our patients have a visual tool to help them understand why we care how they sleep. In addition, CBCT is a big timesaver compared to a full series of X-rays, with the benefit of a much lower dose of radiation exposure. That’s a win-win.

We prefer the Orthophos SL Imaging system to provide better visualization of the airway, the entire jaw, the nasal cavity, and

Figure 1: Dr. Elliott loves to help her patients sleep as well as she can.

(She loves to sleep, too!)

Dr. Erin Elliott grew up in Southern California but went away to a small NAIA school in Western New York where she played collegiate soccer and graduated summa cum laude from Houghton College. After graduating Creighton Dental School in 2003, she settled in North Idaho to begin her general dentistry career. She has a special interest in Dental Sleep Medicine. She has lectured extensively on this topic and loves to help general dentists extend this life-saving service to their patients. She is an active member of her local American Dental Association, the American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and is the past president and a diplomate of the American Sleep and Breathing Academy. She’s teaching sleep apnea with 3D-Dentists and Dr. Tarun Agarwal as well as privately coaching practices about sleep.

DentalSleepPractice.com

11

COVERstory patient workflow from airway analysis, to OSA diagnosis, all the way to ordering and delivery of the oral appliance at the optimal position. OPTISLEEP is the preferred appliance in our practice when we can utilize it.

As a digitally fabricated device, it is stronger and slimmer than analog sleep appliances, making it more comfortable and longer-lasting for patients. With the OPTISLEEP appliance, we get strength without the bulk.

Patient Satisfaction in Practice

Figure 2: SICAT® Air Software with Primescan STL images inputted in preparation for ordering the OPTISLEEP oral appliance.

sinuses (my favorite). SICAT® Air software facilitates seamless image-sharing to assist in educating patients and setting a treatment roadmap.

Orthophos SL is part of the Simple Sleep Solution, a full-service offering of 3D imaging and digital dentistry workflow. Another key component of the Simple Sleep Solution is MATRx plus™, a device capable of performing both a standard home sleep apnea test and an oral appliance trial. It has a userfriendly, tablet-based interface with walkthrough instructions for patients to self-administer the test in their home.

MATRx plus provides real-time, cloud connectivity; sleep study results are sent directly to the dentist’s office and reviewed with the patient. Furthermore, the device is equipped to identify a therapeutic protrusive position to determine the optimal placement settings for the appliance. Dentists, working collaboratively with the patient’s primary care physician (PCP) and a sleep specialist as part of a multidisciplinary care team, interpret the study results to determine the presence and/or severity of OSA along with possible treatment options.

The Simple Sleep Solution is truly an end-to-end platform – it streamlines the

12 DSP | Winter 2020

Rodney is a patient in our practice – and a close personal friend we treated for OSA. Rodney is in his 50s and is a healthy, former triathlete who’s continued to live an active lifestyle. However, he had recently put on some weight, his sleep had worsened, and he woke up with a sore throat every morning. After suffering repeated nighttime panic attacks, he showed up at our office with his figurative “tail between his legs.” We planted seeds with Rodney for years, and he finally conceded that it was time to have a sleep test.

This goes to show that you never know when your message to the community will connect with an individual patient. You can’t predict when a patient will be willing to accept that it’s time to take the first step in solving their problem. You won’t win over every patient every time you bring up the issue of sleep. So be persistent, be consistent, stay motivated, and don’t get discouraged.

There are many Rodneys in every general dentistry practice.

When I saw Rodney, I brought up the possibility of prescribing CPAP after his initial diagnosis of severe OSA (AHI 47 with severe oxygen desaturation levels). However, he was vehemently opposed to CPAP. We agreed to try a home sleep test with MATRx plus to assess his candidacy for an oral appliance. To my surprise, the MATRx plus study results indicated that he could be successfully treated with an appliance.

Rodney had a great experience with MATRx plus. He was so well-rested that he wanted to keep the temporary oral appliance/titration trays from his sleep study. Just as important, Rodney and his PCP were confident that oral appliance therapy (OAT) was the right treatment for him. (Before most sleep apnea patients go through the process of getting an oral appliance and paying for

COVERstory it, they want to make sure it’s going to work.)

Rodney paid cash for two appliances (one as a backup) and feels rejuvenated. Now he’s telling friends and family who have sleep problems to “get over themselves” and take care of their condition. He’s become a vocal proponent for sleep, oral appliance therapy, and my practice. He’ll tell anyone that will listen about his positive experience.

Empowering Patients and Building Trust

Assuming a patient is seen regularly (i.e. about twice a year), general dental practices are uniquely positioned to evaluate sleep disorders. With the Simple Sleep Solution, we have added new procedural options with 3D imaging to our repertoire. By adding images to our exams, we can help patients grasp the nature of their condition. Equipped with this information, both the patient and their healthcare providers are more likely to trust the treatment we prescribe and to believe it will make a significant difference in their lives.

Experientially, the more a patient is engaged, the more likely they are to understand and “own” their condition and be motivated to do something about it. They are more inclined to come back for additional services when needed, such as restorative dental work, and to refer their family and friends for comprehensive oral care consultation and treatment. Again, it’s a true win-win.

Better Technology Yields Better Results

With dental practitioners playing a more prominent role along a patient’s continuum of care, OSA treatment with oral appliances is an area of growing interest and opportunity.

However, OAT is only being used in roughly 5-10% of the OSA population,3 despite data that shows that 50-60% of all sleep apnea patients may be appropriate oral appliance candidates.4 To deliver a better sleep medicine offering, it behooves practices to invest in next-generation 3D technology, such as a large field-ofview CBCT system like Orthophos SL-Ai. The Simple Sleep Solution provides a complete toolbox for practitioners, with a significant ROI and empowers us to: • Eliminate appliance failure • Improve compliance • Decrease time to treatment

Figure 3: Rodney’s MATRx plus™ results show that he is a responder and shows the ideal target position.

• Shorten office visits • Increase patient satisfaction through improved education and awareness The bottom line is that our patients will thank us for providing a better therapeutic experience and for getting them the help they didn’t know – or didn’t want to admit – they needed. Now repeat after me, “WIN, WIN!”

1.

2.

3.

4.

American Dental Association. Oral Health Topics: Sleep Apnea (Obstructive). https://www.ada.org/en/member-center/oralhealth-topics/sleep-apnea-obstructive. Accessed on September 17, 2020.

Surani SR. Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together? World J Diabetes.

2014;5(3):381-384.

Charkhandeh S, Kuhns D, Kim S. A fully digital workflow and device manufacturing for mandibular repositioning devices for the treatment of obstructive sleep apnea: a feasibility study. J Dent Sleep Med. 2017;4(4):97-102.

Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827.

DentalSleepPractice.com

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BIGGERpicture

Apples to Aardvarks Comparing OAT & PAP Monitoring

by Suzanne Mericle, DMD, and Jeff Wyscarver, RPSGT

“W

hen performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates.” – Karl Pearson

A poll of approximately 100 Board-Certified sleep physicians revealed that 68% believed CPAP works well. However, only 55% responded that Oral Appliance Therapy (OAT) works well.1 These physician biased perceptions result in PAP being prescribed more than ten times as often as OAT. Making PAP efficacy is these statistics even more surprising is if you describe oral appliance therapy and rather high, but CPAP therapy to an undiagnosed apneic, patient compliance 80% will select OAT. So why are 92% of prescriptions for OSA treatment for CPAP is relatively low. when 80% of patients prefer OAT? I recently conducted an unofficial poll The inverse is someof 40 dental sleep medicine (DSM) pracwhat true with OAT; titioners and 15 of them reported, “ask high compliance the patient how they are doing” as their methodology to determine OAT efficacy. but efficacy data Subjective reporting as a standalone when is murkier. assessing a sleep disorder is definitely negligent and potentially perilous.

Sleep centers commonly perform split night studies. An attended polysomnogram (PSG) is performed for the purpose of diagnosing OSA. Once sufficient evidence of OSA is recorded, the attending polysomnographic technician implements a trial of nasal PAP to determine the PAP pressure required to eliminate or greatly reduce the presence of disordered breathing. The second phase of titration comes in the form of PAP devices that auto-titrate. Internal “smart” technology determines the amount of PAP pressure required to nor-

14 DSP | Winter 2020

malize the airway on a continual basis. Many PAP systems delivered today are auto-titrating units which essentially circumvent the need for a specific PAP setting previously determined by a titration study.

One of the unexpected outcomes of the Covid-19 pandemic is that the titration portion of PSGs are not being performed out of an abundance of caution. Due to Covid-19 and concerns about the aerosol risk inherent to split night studies, many sleep centers have eliminated PAP titration and split night studies. They are only conducting diagnostic PSGs. Historically, omitting the titration process was unthinkable, but now it is the standard of care in many environments. The American Academy of Sleep Medicine (AASM) has stated “… when the possibility of increased risk to others exists, positive airway pressure delivered via mask should be based on a thorough risk-benefit analysis…”2 Let’s now discuss what happens once a patient is diagnosed with OSA and is either wearing an auto-PAP (APAP) or an oral appliance and how compliance and efficacy are monitored.

Comparing Apples to Aardvarks

I’ll paraphrase business management legend, Peter Drucker, “If you can’t measure it, you can’t improve it.” This is certainly true of sleep therapeutics. PAP efficacy is rather high, but patient compliance is relatively low.3 The inverse is somewhat true with OAT; high com-

BIGGERpicture

A.

Figure 1: AirView Report™ – ResMed Sample compliance report for 30 days

pliance but efficacy data is murkier.3 APAP units provide a variety of parameters such as a flow signal and hours per night used via technology built into the APAP devices (Fig.1). These data are transmitted to the durable medical equipment (DME) provider to document compliance and efficacy for each of the initial 90 nights. This compliance information is so essential that DME companies do not get reimbursed unless it is documented the patient is using the PAP device a minimum amount of time for the first 90 nights.4 Dentists are not currently tasked with providing this information, and among many physicians, this is a common reproach leading to the dearth of OAT prescriptions. To measure OAT effectiveness post-treatment, Home Sleep Tests (HST) or pricey PSGs are usually performed for up to two nights. How does a clinician determine if the OAT titration process is efficacious over a period of multiple nights? And what about compliance? The differences between PAP and OAT as it relates to monitoring is like comparing apples to aardvarks.

The Current State of Affairs

The DSM profession has taken steps in the right direction. A growing number of dentists use an oximeter for multiple nights to gather measurable oxygen saturation information as an indicator of efficacy. This is helpful but still inadequate.

The DentiTRAC (Braebon) provides compliance data, but this device is not available for many appliances and doesn’t provide any efficacy information (Fig.2).

More useful data about efficacy and compliance over a longer period of time is needed. How can DSM clinicians assure our physician colleagues that a shared patient’s OAT is efficacious, and they are compliant for a significant window of time?

Dental Remote Patient Monitoring (DRPM) is the answer.

B.

C. Figure 2: A. SomnoMed appliance with a DentiTRAC. B. Download station. C. Compliance Report

Suzanne R. Mericle, DMD, has been practicing for 29 years in her hometown on Saint Simons Island, Georgia. She attended the University of Georgia where she received her BS in Microbiology. She then attended dental school at the Medical College of Georgia and graduated in 1991 with honors. Dr. Mericle is an instructor/lecturer for Glidewell Dental, DenMat, Dental Excel, and Practical Sleep Education. She has written several articles on Dental Sleep Medicine, Periodontal Disease, and several others on dental products.

Dr. Mericle is a diplomat with ASBA, Qualified Dentist with AADSM, and has her Fellowship with DOCS. She maintains professional membership in the Georgia Dental Association, Academy of General Dentistry, the Dental Organization for Conscious Sedation, the American Academy of Dental Sleep Medicine, and the American Sleep and Breathing Academy.

Jeff Wyscarver, RPSGT, is a registered polysomnographic technologist and president of DDME (www.ddmeonline.com • 1-800-513-9337), a company that brings sleep lab technology and services to the dental community.

DentalSleepPractice.com

15

BIGGERpicture

A.

B.

Figure 3: A. CIRCUL Wearable Sensor. B. SPO , Heart Rate, and Sleep histogram (wake, light, Deep REM) 2

What is DRPM?

Recent advancements in wearable technology have produced a great solution for dentists.

Monitoring a patient’s titration for a few weeks, months, or longer provides several advantages and addresses the previously detailed shortcomings. Measuring sleep over many nights DRPM empowers is achievable due to a new wearable techyou to monitor nology – the CIRCUL. The CIRCUL indicates efficacy through SPO2, heart rate, and a 4 your patient’s stage Sleep Quality histogram: wake, light sleep, deep sleep, and REM sleep (Fig. 3). treatment efficacy We propose these parameters provide better and compliance. data than APAP devices as they measure the actual patient’s response to therapy, as opposed to the performance of the equipment.

By presenting dentists with a trove of real-time efficacy information, the CIRCUL can improve OAT patient outcomes. This data sharing creates a compelling story that ensures patients are engaged in their therapy. This can create an element of gamification which has been demonstrated to improve health outcomes.5 Implementing DRPM into a practice is simple, and there are 4 relevant billable codes, so we have a clinically sound improvement coupled with new reimbursement codes.

There are two business models available to achieve DRPM using the CIRCUL: 1. The CIRCUL is available for less than $300. It can be dispensed and reused by the dentist similar to how oximeters are dispensed today. However, the CIRCUL can be used for longer stretches of time at half the cost of traditional oximetry with twice as much meaningful data collected.

2. Alternatively, the wearable can be sold directly to the patient.

16 DSP | Winter 2020

According to CMS, there are multiple RPM codes available. Per CMS, you can bill for these codes if you are a “physician or other qualified healthcare professional.” (See Table 1.)

Table 1: CMS Billing Information (ICD-10) Description

Code

Medicare $

Issue a home monitor & training

99453

$19.46

Provide patient sensor

99545

$64.15

Monitor for at least 16 days

99091

$58.38

Treatment management

99457(8)

$51.54

Little discussion has been devoted to the distinction between PAP therapy and OAT as it relates to the titration process. This distinction is one of the primary reasons the medical community has been reluctant to adopt OAT as a preferred treatment modality. DRPM empowers you to monitor your patient’s treatment efficacy and compliance. This will lead to healthier patients actively engaged in their treatment and more physician referrals as they realize that we’re comparing apples to apples.

1.

2.

3.

4.

5.

Grannick, L (2019). Sleep Physician OAT Prescription Trends.

Fletcher Spaght International.

“COVID-19: FAQs for Sleep Medicine Clinicians and Sleep Facilities: AASM.” American Academy of Sleep Medicine – Association for Sleep Clinicians and Researchers, American Academy of Sleep Medicine, 28 Aug. 2020, aasm.org/covid-19-resources/covid-19faq/.

Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial “Positive Airway Pressure (PAP) Devices - Clinician Frequently Asked Questions.” Noridian Medicare, Noridian Healthcare Solutions, Dec. 2008, med.noridianmedicare.com/documents/2230703/17635061/PAP+Devices+FAQs. Johnson, Daniel, et al. “Gamification for Health and Wellbeing: A Systematic Review of the Literature.” Internet Interventions, Elsevier, 2 Nov. 2016, www.ncbi.nlm.nih.gov/pmc/articles/ PMC6096297/.

PRODUCTspotlight

No More Porridge by Mark T. Murphy, DDS, D.ABDSM

E

volution refers to the gradual development or changes in something over time. Revolution means ‘a turnaround’; a sudden, complete, or radical change in something, occurring in a “staggeringly” short period of time. The ProSomnus® [IA] was unquestionably ‘revolutionary.’ As the first iterative design, first precision engineered platform, and first control cured, milled PMMA, it was met with skepticism, and a doubtful attitude that seemed to shout, “that will never catch on.” That was 2014, and just six years later, it was the most prescribed device in North America last year. I know, there are more prescriptions for various generic Herbst, dorsal, and other devices, but by single manufacturer and design the ProSomnus [IA] is #1.

Ask average dentists which ‘new’ concept they like the best and they lean toward the one that stands out the least, gravitating to the one that provides slight improvements over everything that’s been on the market.

Time and time again we have seen small changes to old products fit this scheme. Legacy devices made from acrylics, using ball clasps for retention, soft liners for comfort or printing nylon which is hard to clean are small changes to the status quo. ProSomnus’s use of control cured milled PMMA was a revolutionary new material, design, precision engineering and manufacturing process. It has allowed ProSomnus to manufacture a family of precision devices that prevent tooth movement and are super easy to clean.

This sea-of-sameness that exists is why other manufacturers are fighting a price war in a field filled with commoditized products. Another Herbst. Another dorsal.

Another soft liner. Curt Bailey, the president of Sundberg-Ferar, a Metro Detroit innovation design studio, calls this sameness, ‘the porridge.’ Curt continues on, “With a nod to Goldilocks, these products are not too hot, not too cold, they’re just right. They are also warm, mushy, and bland. In their zeal to be just right for everyone, they’re not really special to anyone.”

So, what is next?

sicians are not happy with ‘the porridge.’

The legacy materials and handmade manufacturing processes do not provide the level of precision, comfort, hygiene, and performance that physicians demand and expect for their patients. Oral appliances have to evolve from the old to the new. Precision design, engineering, and processing along with better materials can raise the bar from being just part of a dental lab to true medical device manufacturers. Handmade porous cold cured acrylics, soft silicone liners, or flexible biogunk incubating printed nylon simply do not meet the needs of precision medicine today. You are seeing more control cured PMMA, CAD/CAM, intentional precision and innovative engineering designs and materials surface. Soon you will see an even more dramatic innovation in material technology; a flexible, strong, precision milled platform. Designed to help make your work easier and earn the trust of sleep physicians and payers, this material innovation will have all the attributes you are accustomed to with the ProSomnus platform but with added flexibility and strength. Made from a proprietary MG6™ medical grade technology and material, it is virtually indestructible, easy to deliver, and has the same precision and ease of cleaning you have come to expect from ProSomnus. If dentists want to earn more prescriptions from sleep physicians, we need to ditch the porridge!

ProSomnus MG6 material changes everything. Evolving soon!

Pending FDA Clearance

Mark T. Murphy, DDS, D.ABDSM, is an American Board of Dental Sleep Medicine Diplomate and has practiced in the Rochester area for over 35 years. He is the Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, Principal of Funktional Sleep, serves on the Guest Faculty at the University of Detroit Mercy School of Dentistry and as a Regular Presenter at the Pankey Institute. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor. He lectures internationally on Leadership, Dental Sleep Medicine, TMD, Treatment Planning, and Occlusion.

Unfortunately for dentists, sleep phyDentalSleepPractice.com

17

EXPERT view

In Your Own Words

P

roviding life-saving care for patients is the #1 reason dentists get involved in Dental Sleep Medicine (DSM). Issues related to medical billing seem to be the #1 obstacle dentists cite for abandoning DSM. You provide the best treatment money can buy, so you expect to be compensated appropriately. This is where the frustration, disappointment, and confusion can set in.

In each issue of Dental Sleep Practice, we ask numerous experts three questions. No one, not even the most prolific DSM practices, sees more cases than the top DSM billing companies. In hopes of helping you avoid or overcome medical billing pitfalls, we asked CEOs from the most highly regarded DSM billing companies the following questions about best practices and ways to avoid self-sabotage. These are the responses “In Your Own Words.”

1. What is one way practices consistently sabotage their medical billing success?

2. What is one best practice your most successful clients have in common?

3. What’s one piece of PRACTICAL advice you want to impart on readers that they can use tomorrow?

Randy Curran Pristine Medical Billing

1. While all practices go into this venture with the best intentions, many practices fail to follow the proper workflow. The insurance carriers have given us the playbook with policies, but at times the dental practice will try to call an audible on the play and deliver an appliance before a pre-authorization or gap has been approved. It’s imperative to listen to the advice of a third-party expert when setting up the workflow and documentation protocols to ensure reimbursement. Don’t be a lone wolf.

2. A strong dedicated team member that is willing to learn new things, has an open mind, is patient with the process/protocols, and is given the time and support to implement a new program. Every bada$$ DSM practice has a bada$$ quarterback leading the charge. The practice that truly understands that dental sleep medicine will take some time and payroll to develop the program, will always have the advantage over the practice who desires immediate results with minimal effort.

18 DSP | Winter 2020

3. Be patient with the process. Understand that building a dental sleep medicine program is a marathon not a sprint. Start simply with your own patients and set a goal of two appliances per month for the first six months. Small victories are still victories. Then double that goal every six months. Within two years the goal is 16 per month and that would put you at the level of the elite DSM practices across the country. While doing this, the practice will methodically develop the best strategies for their unique business. Also, understand that medical insurance is just part of the payment and not the magic wand. The practice still needs to do a good job of articulating the medical urgency to convert the treatment.

Lesia Crawford GoGo Billing

1. Missing medical documentation is the most common weapon of destruction in sabotaging a claim payment. The doctor and team can do everything exactly right in regard to patient care, but if they don’t have the very specific paperwork the insurance requires – *POOF* – no claim payment.

2. The medical files should read like a story. We can tell who is working with their MDs because the full story can be told.

The story begins with when the apnea was suspected, screening was performed, patient was tested, and treatment was ordered. Some get a little more complicated than that, but it makes for interesting reading. Dental offices who do a great job communicating with their referring offices and send patients back and forth are always the most successful. The offices that try to patchwork a case or do everything themselves, they end up quitting.

3. Trying to track down an old sleep study?

STOP! Refer them out for a new consult visit and test. If the study is less than a year or two old, and the patient is not eager about a new one, try calling the sleep lab directly. Have all your patients sign a records release consent form and bypass the PCPs or specialists if needed.

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Bradley Eli, DMD Encinitas, CA

Get started today! *Price does not include shipping or applicable taxes. Glidewell Clinical Twinpak is valid for two appliances for the same case. † Silent Nite stops the snoring or return it within 90 days for a full credit.

Clinicians Report® is an independent, nonprofit, dental education and product testing foundation, Clinicians Report®, September, 2019.

For the full report, visit glidewelldental.com/essential-product.

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EXPERT view Rose Nierman Nierman Practice Management

1. This can be summed up with two words – insufficient documentation! Medical insurers require a higher level of detail of clinical notes than dental insurers, so it is imperative that dental practices become proficient in documenting in SOAP format (subjective, objective, assessment, plan) to ensure successful reimbursement. Knowing the correct codes is surely important, but it’s the documentation that will make or break your case! Utilizing a system to organize and drive this is key.

2. This one can be summed up into one word – communication! Ample communication with the medical community is by far the most common trait we observe in successful practices. A stable communication protocol consisting of written communications to the patient’s referring doctor and other providers they see, plays a critical role in both securing referrals and reimbursement. Physicians want to know the patient’s oral appliance progress and medical insurers may require documentation from the treating physician to approve reimbursement.

3. Get educated on DSM and medical billing for dentists. I cannot stress enough the importance of educating all involved parties in the dental office. The patient perceives the dental practice’s level of knowledge and comfort in DSM starting with the first phone call. The administrative, clinical, and medical billing team (whether in-house or 3rd party) all have a significant impact on the patient’s decision to accept treatment. Hence, our motto: Get your ducks in a row!

Megan Cheever Brady Billing

1. Medical billing is so different than dental billing. Generally, practices are expecting the same processes and guidelines with medical billing. Trust your biller! Erase all the things you know about dental billing and find a reputable biller to help lead the way. Then replicate that over and over for your patients! Your billers want to get you paid!

2. Well trained teams! A doctor who is successful educates every part of their team and allows them to work as a unit from

20 DSP | Winter 2020

the very beginning. The best thing you can do is hire someone to be dedicated to sleep instead of letting it be an “add on” to an existing employee’s duties. I think you’ll find a dedicated employee (or team in a lot of cases) will work a whole lot harder to make it succeed!

3. Communicate, communicate, communicate! Ask your billers what they expect of you, and let them know what you expect of them! When a biller can manage your expectations from the beginning, you’ll find your processes will run more smoothly and you’ll know what to expect regarding billing. They can help you to understand what can reasonably be controlled and what we leave to chance with insurance.

Lisa Fischer-Herdt 4 Pillar Billing

1. Practices mistakenly assume that medical and dental billing are similar. Offices may have effective protocols for dental billing and attempt to utilize the same systems, protocols, and philosophy in medical billing. To make matters worse, these offices often fail to seek help from experienced medical billing companies. It is a recipe for failure. My advice is to initially set a reasonable cash fee to begin gaining experience in DSM while developing your billing protocols.

2. In short, well defined workflow and responsibilities. Most successful DSM practices are driven by leaders who share a clear vision of their goals while establishing well defined DSM systems and team member roles to achieve that end.

Successful practices have an in-depth understanding of each step of DSM implementation, have a well-defined process for accomplishing those procedures and have clearly designated responsibilities for those actions.

3. Don’t overthink or delay treating your patients. We have witnessed far too many offices who feel they just need one more course, a little more time, or who use one of hundreds of other excuses to prevent them from getting started. Meanwhile their patients and practices are suffering.

This isn’t that complicated. You will learn to do this just like you learned how to do dentistry – by doing! Get started now!

Which Device Best Fits Your Patient’s Needs?

One of the best ways to maximize treatment success is to select the proper sleep appliance for your patient. To make your selection, consider the clinical situation of each patient, as well as the key features of each appliance.

Each appliance is available as an optional “One for Relief, One for Reserve” Glidewell Clinical Twinpak™ to help ensure patients never go untreated.

OASYS Hinge Appliance ™

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EMA®

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dreamTAP ™

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by Gordon J. Christensen Clinicians Report® as an appliance “dentists can’t live without.”

*Price does not include shipping or applicable taxes. Glidewell Clinical Twinpak is valid for two appliances for the same case. †

Silent Nite stops the snoring or return it within 90 days for a full credit.

Clinicians Report® is an independent, nonprofit, dental education and product testing foundation, Clinicians Report®, September, 2019. For the full report, visit glidewelldental.com/essential-product.

OASYS Hinge Appliance is a trademark of Dream Systems LLC. EMA is a registered trademark of Frantz Design Inc. dreamTAP is a trademark of Airway Management Inc. AM Aligner is a product of Airway Management Inc.

877-210-3338 800-854-7256 glidewelldental.com glidewelldental.com

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PRACTICEmanagement

2021 Office Visit Code Changes A Positive Impact for Your Bottom Line

by Rose Nierman, Founder & CEO Nierman Practice Management

I

know. I get it. Medical coding may not be the most exciting subject matter, but trust me on this one – it’ll pay to keep reading! It will be worth the time, and the information may even increase your bottom line. Much anticipated and long overdue updates to office visit codes, referred to as evaluation and management (E/M) codes, promise to improve the patient experience and save dental practices time and aggravation when billing medical insurance for office visits.

We’re getting to the place where we’re documenting what’s important for patient care and for communication with our colleagues.

22 DSP | Winter 2020

The documentation requirements for E/M services were established ages ago (one set of guidelines was written in 1995 and another in 1997) and have been in desperate need of revision. Beginning January 1, 2021, changes to the Current Procedural Terminology (CPT®) structure for office E/M services take effect. Thankfully, the documentation guidelines have been totally revamped!

Previous documentation guidelines did little to support patient care. Instead, they served more as a scoring system to justify a level of office visit billing (e.g., level 2, 3, or 4), rather than help providers diagnose, manage, and treat patients. This adherence to E/M documentation guidelines consumed a significant amount of time and did not necessarily reflect the actual work of providers.

How the new guidelines help providers with office visit requirements: • Eliminate the exam as key elements for code selection • Allow providers to use medical decision making (MDM) or total time spent as the key element for code selection.

• Modify MDM criteria to move away from simply adding up tasks to focus-

ing on tasks that affect the management of a patient’s condition.

The new CPT guidelines lean more toward time spent caring for patients rather than spending time calculating how many “body systems” or “bullet points” are reviewed or assessed. Dr. Barbara Levy of the CPT editorial board states, “I think the new guidelines will be far more intuitive. For doctors, it’s going to be terrific.”

Coding from the SOAP Report

Dr. Levy explained that the new E/M documentation will be more strongly based on the traditional SOAP – subjective, objective, assessment and plan – in which providers document what the patient was there for (subjective), what was learned from their history and exam (objective), and then what the provider judged to be the problem (assessment), and the strategy (plan) for dealing with it.

Primary objectives of the CPT office visit revisions 1. Decrease administrative burden of documentation and coding.

2. Abate the need for audits on this coding set.

3. Reduce documentation not needed for patient care in the medical record.

Were any codes deleted?

Yes, CPT code 99201 for a new patient problem focused history & exam is officially deleted from the Current Procedural Terminology (CPT) medical code set as of January 1, 2021 since it was similar to the level 2 code. This deletion is not considered an issue since DSM dentists typically spend more time in consultation than this code reported.

PRACTICEmanagement Is the established patient level 1 exam code still valid?

Yes, level 1 code, CPT 99211, for established patients has not been deleted. You can still utilize this code in 2021.

Can the established patient code, 99211, be selected for a patient’s time with my clinical staff?

Yes, you can use 99211 for staff who perform face-to-face encounters. 99211 is for a minimal problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision.

Can dentists now select E/M based on Total Time Spent?

Yes, providers can select an exam level based on their time providing care even when not face-to-face. Additionally, providers will not need to specify that counseling and coordination of care dominated the visit to use time to support the level of care.

Table 1: 2021 Requirements for E/M Codes 99202-99205 Code

History/Exam

99202 99203 99204

Medically appropriae history and/or examination

99205

MDM

Total Minutes

Straightforward

15-29

Low

30-44

Moderate

45-59

High

60-74

MDM

Total Minutes

Straightforward

10-19

Low

20-29

Moderate

30-39

High

40-54

Table 2: 2021 Requirements for E/M Codes 99212-99215 Code

History/Exam

99212 99213 99214

Medically appropriae history and/or examination

99215

Note: 99211, established patient E/M code, is still available, but its code descriptor does not include a time reference

See Tables 1 and 2 for new guidelines with time ranges for total time spent.

Since we can now bill based on Total Time Spent, what is included?

There is a long list of activities that can be considered for total time spent! It includes time in activities that require the physician or other qualified health care professional but does not include time in activities typically performed by clinical staff. Here are some examples: • Preparing to see the patient (i.e. reviewing test results) • Obtaining & reviewing history • Performing the exam/evaluation • Counseling/educating the patient/ family • Ordering meds/tests/procedures • Communicating with other health care professionals • Documenting clinical information in the chart/health record The SOAP format is much more intuitive than the checking of predetermined bullet points to document care. “That’s the way our brains work,” says Dr. Levy. “We’re getting to the place where we’re documenting what’s important for patient care and for communication with our colleagues.” With these new guidelines, dentists and their teams can now choose the level of E/M code for their visits with confidence from their SOAP reports – as it should be!

We at Nierman Practice Management welcome these changes with open arms and excitement, as the ability for the dental practice to use total time spent as the key factor for selecting the appropriate level of E/M code is very beneficial. This simplifies the selection criteria and now allows for higher levels of office visit codes to be utilized than ever before. For a link to the new E/M guidelines, please send a request to my office at Contactus@dentalwriter.com.

Rose Nierman’s CrossCoding: Unlocking the Code to Medical Billing in Dentistry course is available in-person, live-stream, or as an online course. Rose and her team have helped thousands of dental practices implement medical billing for DSM, TMD, and oral surgeries. Her company, Nierman Practice Management, created DentalWriter™ software to generate SOAP narrative reports and claims for dentists billing medical insurance in-house or as outsourced billing. Rose and her team have been dedicated to helping dentists and their teams for 32 years. For more information: contactus@dentalwriter.com or 800-879-6468.

24 DSP | Winter 2020

INtheLAB

Laser Sintering New Life into Your Sleep Appliances

G

reat Lakes Dental Technologies has fabricated sleep appliances for over 25 years. In that time, fabrication techniques have evolved to take advantage of traditional materials such as acrylic and wires. Optimization of these appliances within the confines of the materials’ characteristics created some uncrossable boundaries. Balancing the qualities of fit, strength and durability, comfort and flexibility, as well as cost has always been a challenge.

The advent of 3D printing in dentistry, or more specifically, the application of additive manufacturing to create appliances rather than models has opened new opportunities for appliance design that were previously impossible.

The Herbst®* sleep appliance is a popular and widely used appliance that is ideally suited for the application of 3D printing technology.

Here we discuss two innovative versions of the Herbst sleep appliance – one laser sintered Experienced from nylon and another laser melted from chrome-cobalt. technicians Traditionally, the Herbst appliance translate years of fabrication technique features several labor-intensive and skilled steps includbench experience ing bending heavy wire framework for into the digital reinforcement, adapting acrylic and thermoplastic for structure, and placement of design process. hardware which is critical and requires skill and experience to perform by hand.

The challenges or limitations include requiring a technician with experience and skill; both in wire bending and acrylic and trimming procedures. A lengthy training time for technicians is typical. Appliance durability is only increased by wire framework or adding acrylic bulk. The added bulk is a deterrent to patient compliance and occupies valuable tongue space. Additionally, the Herbst appliance is still subject to fracture and wear from the destructive forces of bruxism.

in crown, bridge, removable partial denture (RPD) frameworks, and nylon applications in sleep; examples include the Narval and Panthera D-SAD™ appliances. Laser sintering requires a comparatively large capital investment compared to traditional skilled fabrication but will become more common and accessible as the technology matures in the dental space.

The technology allows for digital design of appliances. The laser melts layers from a bed of dry powder, rather than curing layers of liquid resin with light. Laser sintering yields a wider variety of different material properties.

Nylon Laser Sintering

For a Herbst appliance, using laser sintered nylon results in a very thin and comfortable appliance. A nylon “overlay” substructure is created to receive custom Herbst pivot hardware. The advantages include an aesthetically favorable white plastic, an extremely durable and strong appliance that also features uniquely flexible properties.

The nylon Herbst appliance can be made very thin (less than 1mm thick), and it will still be incredibly durable and retentive while maintaining its flexible nature at this thickness. This makes the appliance easier to insert and much more comfortable for the patient.

The low-profile design precisely engages the undercuts to enhance retention and fit.

Post-processing of the sintered parts is a significant component of the workflow, and one that should be specially adapted to each type of part being fabricated. Nylon sintered parts require depowdering after removal from

Laser Sintering

Laser sintering technology has been around for years. Its application in dentistry is more recent – specifically metal applications

Nylon Herbst sleep appliance

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INtheLAB the machine. This can be done by hand with a media blasting cabinet. It can also be automated with rough tumbling.

After depowdering, polishing can be accomplished by hand or by a largely automated tumbling process with several media stages. Some dental parts, including most sleep appliances, are well-suited for isotropic finishing. However, some appliances such as splints require a more targeted approach to preserve the critical accuracy of the occlusal contact area.

Metal Laser Sintering

Digital design of metal appliance

Metal sintering technology allows for a removable Herbst sleep appliance with an entirely metal framework and no added acrylic. Appliance fabrication using metal laser sintering technology relies less on manual technician skill and is extremely consistent.

The Herbst framework is laser sintered in chrome-cobalt to which Herbst pivots are then also laser welded. The metal sintered appliance is very strong and can use an RPD-style skeleton to support the Herbst pivots, reducing the overall bulk and creating the lowest profile appliance possible. Retention is designed like removable partial dentures, with the undercut being engaged precisely.

Experienced technicians translate years of bench framework for Herbst sleep experience into the digital design process.

The framework is designed in software, so the clasping is accurate and effective. Hard-

ware placement is simulated in the software to ensure comfort and freedom of movement.

Metal sintering requires significant postprocessing. Support structures are created with every part, and then must be removed prior to finishing. Care and effort are taken in the initial stages of design to facilitate the removal of these supports. These parts, like nylon, require an initial rough surface improvement to depowder and prepare for subsequent stages.

Metal sintered parts can be finished by hand, requiring several stages of grinding with a stone wheel to smooth the part sufficiently for polish. The parts can also be efficiently tumbled in a variety of tumbling machines to produce a desirable smoothness. Electropolishing can also be used as a final polishing stage.

Fabrication consistency is high and appliance records can be kept indefinitely. Design parameters of appliances can be controlled more objectively, and in some cases quantified, creating better communication between labs and doctors. Highly technical elements are reallocated to the digital design portion of the workflow providing opportunities for work to be done remotely. As laser sintering technology becomes more accessible to labs, the main differentiating factor will be the quality of the digital design – anchored by the experience and skill of technicians.

Digital design of appliances is the future of lab work. Leveraging new materials and fabrication techniques pushes the design and appliance effectiveness further forward and creates better diagnostic and therapeutic experiences for patients. Great Lakes Dental Technologies is committed to this pursuit and has sintered it into product development and appliance fabrication operations.

About Great Lakes

Great Lakes Dental Technologies is an employee-owned company, with 186 employee-owners who design, develop, manufacture, and market appliances and products for use in the orthodontic, dental, and sleep and airway markets. Great Lakes is one of North America’s largest orthodontic laboratories and offers more than 4,000 products and services. Training and education on the latest appliance fabrication techniques and equipment is offered online and at the onsite training center at the company’s headquarters.

Metal framework removable Herbst sleep appliance

26 DSP | Winter 2020

*Herbst is a registered trademark of Dentaurum, Inc.

Effective Sleep Solutions.

Trusted Experience.

Great Lakes.

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clinically proven sleep appliances.

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800.828.7626 GreatLakesSleep.com * Herbst is a registered trademark of Dentaurum, Inc.

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COMMUNICATIONS

Coffee is for Closers: Get Out of Your Own Way

by Michael Cowen

“I

don’t understand. You’re telling me your treatment plan conversion rate dropped from 70% to 16%?” Perplexed, I exclaimed, “This makes no sense, Todd!” My friend, “Todd”, owns a successful general dentistry practice in the Midwest and has been treating sleep apnea for a few years.

But in the last several weeks, there were 30 patient consults and only 5 moved forward with treatment. What happened?

And that’s when Todd expelled the dirgelike chorus of our day, “COVID.” Todd’s practice experienced the pain of forced closure, the sting of lost revenue, and the perceived “nail in the coffin” of significant staff turnover upon reopening. Sound familiar?

Whether you are feeling overcome by challenges, battered by the storm of COVID, or just questioning if this is really the path for you, I encourage you to stay the course. In the The…purpose of famous words of Abraham Lincoln, “Things the…Treatment may come to those who wait, but only the things left by those who hustle.”

Plan is to create a So, let’s get our hustle on! Turn face-forward into the winds of adversity, push clear path of value ahead, rebuild the team, and make the necto which the essary pivots toward future success.

The next step in my friend’s story inpatient can afford volved reviewing and tweaking what was to say “yes.” occurring (or not occurring) in his sleep consults, more specifically his Financial Treatment Plan.

The Basics

First, let me share a few key details about Todd’s practice: • Contracted with most dental insurances in a rural Midwest state • Operates their sleep program on a FeeFor-Service (FFS) model • Charges a single, demographic-appropriate fee for a comprehensive treatment plan • Always follows the direction of an overseeing physician for airway treatment

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Each patient in these sleep consults has the following: • Sleep study report that includes the diagnosis of obstructive sleep apnea and recommendation for oral appliance therapy from a Board-Certified Sleep Physician • All necessary clinical documentation to move forward with treatment

Who’s on First?

At this point, it is important to distinguish between the clinical and financial components of the Comprehensive Treatment Plan.

The Clinical Treatment Plan is your sweet spot and includes the sleep test review, discussing the RBAs (risks, benefits and alternatives) of treatment options, and gaining the patient’s decision to move forward with recommended treatment.

The Financial Treatment Plan comprises the concise recitation of value included, payment options available, and collecting payment from the patient. This is presented by your treatment coordinator, a role we affectionately refer to as “the Closer” on the team because they are ultimately responsible for closing the deal. If the train goes off the tracks here, everything comes to a screeching halt. And that helps no one – no better sleep, no improved health, no increased production.

The Comprehensive Treatment Plan

The singular purpose of the Comprehensive Treatment Plan is to create a clear path of value to which the patient can afford to say “yes.” To accomplish this, we must reinforce the value in the treatment plan. Here are some common items that can be included in the treatment plan: • Case Initiation, Planning, and Consultation

COMMUNICATIONS • Oral Appliance (2-Year Limited Warranty) • Adjustments and Titrations • Titration HSTs • Efficacy Home Sleep Study (with interpretation) If you have additional tests or services that you include with your clinical protocol, this is where you list them. The goal of this format is simple – to ensure that your patients do not feel like they have to spend money every time they come into the practice.

The Closer will briefly discuss each service on the list, clearly emphasizing its value to the patient.

3rd Party Financing

In an FFS model, the role of third-party financing cannot be understated. As a society, we have moved from a “gold standard” to a “credit standard.” We purchase homes, cars, phones, almost everything based on monthly payments. To approach your treatment plan in a way that smacks in the face of standard psychological pricing strategy is not an approach that ends well. Rather than fight the current like the Alaskan King Salmon, go with the flow and reap the benefits.

“But we can’t afford to offer 24-month financing to our patients. It’s too expensive.”

Have you heard someone say this before?

Have you said it? While this may hold true in select in-network/contracted environments where your fee schedule is fixed by an insurance company, it could not be further from the truth when you have control over the fee, communicate your value proposition, and have desirable payment options. Consider these facts: • 24-month financing is less expensive than a “no” • 24-month financing mirrors your warranty and adjustment period for therapy Bottom line: You can’t afford NOT to offer 24-month financing, especially when you control the global fee for services rendered.

Communication Best Practices

Below are a few easy communication pointers to tie this all together and increase your case acceptance rates. Don’t be misled by their simplicity. Communication is the #1 reason that DSM practices fail.

Who says what – Separate your treatment plan into the clinical and financial components. Focus your natural strength on the conversation you are best equipped to handle.

Always Build Value – When the Closer is communicating what’s included in the treatment plan, speak clearly and use simple words. Avoid jargon. Touch each point of the paper with the tip of your pen giving the patient the non-verbal cue to read what you’re telling them.

Payments – Handwrite all of the payment options available, i.e. 6, 12, 18, & 24 month options before presenting to the patient. When it comes time to ask the patient for their financial commitment, consider asking, “Which payment option fits best in your budget?”

K.I.S.S. (Keep It Super Simple) – Most have heard of this principle, though slightly adapted here, and it could not be more appropriate. The quickest way to lose a case is to complicate it.

Period. Keep it simple and get the “yes.”

Keep hustling. Keep tweaking. Keep striving. Keep giving. And you will keep receiving, I promise.

Comprehensive Sleep Apnea Treatment Plan Patient Name: _________________________________ DOB: _________________ Treatment Covered by This Agreement: q Comprehensive Sleep Apnea Treatment Plan • Case Initiation, Planning, and Consultation • Oral Appliance (2-year Warranty) • Appliance Adjustment (2 years) • Titration Visits / Tests • Efficacy Home Sleep Test Fee*: ___________ 3rd Party Financing Options: q ________________ x 6 months q ________________ x 12 months q ________________ x 18 months q ________________ x 24 months Signature: ____________________________________ Date: _________________

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

DentalSleepPractice.com

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BILLINGblocks

4 Axioms for Medical Insurance Success

by Randy Curran and Kyle Curran

I

’ve lived in the medical billing world for nearly 20 years. That’s 20 real years – not the 2 weeks that might feel like 20 years these days. I’ve seen a lot of changes with coding, policies, and procedures and had the good fortune of seeing many practices flourish. I’ve also learned a lot about what not to do. There are 4 axioms – statements that are established and self-evidently true – about medical billing.

Axiom #1 – Medical Insurance is Not a Magic Wand

Some practices register for our services with the mindset that since they hired a billing company, their job is done. They falsely believe that every patient is going to get 100% coverage, and they won’t have to put forth any effort. Although the former is occasionally true, it is not going to be the case for at least half of your patients. Why, you ask? The majority of dental practices across the country are out-of-network providers.

Practices in states like Michigan and Illinois have much easier situations, as their lowest paying PPO carriers allow over $2,400 per treatment and automatically process claims as in-network. Other states such as Alabama and Wyoming have a high penetration of BCBS PPO plans that allow less than $1,000 for oral appliance therapy (OAT). You may want to reconsider if you were thinking about packing up your practice in Wyoming, MI and heading out west to open a new DSM practice in Cheyenne, WY. Like so many other things in life, the key to success is being a student of your circumstances. You must have a solid understanding of how medical insurance is going to work with patients in your state. Once you understand and accept this, you will be able to set the correct expectations of insurance coverage. This will allow you and your team to build case presentations accordingly.

Adopt this way of thinking – insurance can help supplement the cost of the treatment; it

30 DSP | Winter 2020

is not the alpha and omega. If presented well, a practice will move patients forward, even when the patient has to pay out of pocket for most of the treatment due to a high deductible. If you explain that the cost is $1,500, but most of that will apply to the patient’s deductible, and possibly even the family deductible for the remainder of the year, the cost is more palatable as there are collateral benefits to my payment for treatment. Sometimes you have to seek the silver linings.

Axiom #2 – Play by the Rules

This is *NOT* your home rules version of Monopoly that always seems to be slightly different from the way your uncle or best friend plays it. In the game of medical insurance, you must play by the rules whether you like them or not. If you don’t, you definitely won’t pass go, you won’t collect $200, and you might even go to jail. It’s OK if you don’t like it because you didn’t create the game, my friend.

“I’ve billed dental insurance for 30 years and this is/isn’t how insurance works,” is a common refrain sung by newer clients, and it’s way out of tune. You may think the Epworth score is ridiculous or that the STOPBANG has a higher positive predictive value, but the insurance carriers don’t care about your opinion. If you want your pre-authorization approved or your claim paid, you must adhere to their polices. Also, contrary to popular belief, the billing service isn’t making up these rules to make your life harder.

BILLINGblocks Axiom #3 – Implement a Solid System To play by the insurance carrier’s rules, it’s paramount that you establish a consistent, repeatable workflow. We advise all clients to be mindful of state-specific dental board regulations, policies of the insurance carriers most often encountered in the practice, and the recommendations of relevant professional organizations. If you want a program to run smoothly, it will always begin with a solid foundation.

Different insurance carriers require different documentation, and state …you definitely won’t dental board guidance varies across pass go, you won’t the country as well. If you are a dentist in NJ, NY, OH, GA, and perhaps a collect $200, and you few others (dental boards are currentmight even go to jail. ly reviewing this as I’m writing), you cannot order a sleep study. It must be ordered by a medical doctor; the practice can either refer the patient to a local MD or use a system that encompasses a telemedicine visit prior to a home sleep test’s (HST) delivery.

On that note, if you are a Medicare provider, your patients will also need a face to face visit with a sleep physician prior to the sleep study. Under no circumstances can the HST be delivered by the dental practice, as it is a conflict of interest in Medicare’s eyes.

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

Kyle Curran has been active in the Dental Sleep Medicine industry for the past five years and is currently the Director of Client Development at Pristine Medical Billing. During this time, Kyle has managed medical billing processes, training, and proper workflows for more than 100 dental practices across the nation. He stays abreast of the ever-changing field of medical insurance by participating in continuing education and practical experience. As a graduate with a business degree, he is able to help dental practices understand and implement practical business solutions to achieve sustainability in the Dental Sleep Medicine arena.

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Speaking of face to face requirements, United Healthcare updated their dental sleep policy in August 2019 to also include a face to face visit. This face to face visit does not dictate that it must be done prior to the sleep study, though is does state that it must be done with an MD or DO trained in sleep.

Axiom #4 – Patience Is a Virtue Paraphrasing Proverbs, “patience is a virtue”, which is especially true when implementing a dental sleep program poised for long-term success. DSM is like a vineyard. There is seemingly endless toil with no immediate payoff. But once the roots have been established, you will see many years of prosperity that exceed your wildest dreams.

Too often, new DSM practices expect that within the initial 6 months they’ll treat 10 patients per month and add an additional revenue stream of $30,000 or more. This is not reality for most practices. Out of more than 1,000 practices I’ve helped, I can count on one hand the practices that have experienced that level of immediate success. Even in good-paying states like MI or IL, it takes time to get you into the insurances’ systems for payments. Some of your first payments may take 3-5 months with certain Blue Cross/ Blue Shield plans. The carriers are in no hurry to pay out claims.

Maybe you’ve elected to go in-network if your gap approvals have been denied and you’ve found it difficult to close cases.

This will require patience, too. It typically takes 6-10 months to obtain a dental sleep medicine in-network contract. Patience, my friends, patience.

Using medical insurance to help your patients move into treatment can be a great service to your community and your practice.

Ensuring that you have a streamlined, integrated system for managing telemedicine, HST, and medical billing will position you for long-term success and ensure you’re compliant with state, payor, and professional rules and regulations. Lastly, being patient with the process and setting realistic expectations of insurance payments guarantees that your practice will do it right and realize the fruits of your labor for seasons to come.

PRODUCTspotlight

Innovation at Arm’s Length

by Barry Chase, DDS

O

ver many years of practicing dental sleep medicine, I have become a big proponent of the Herbst appliance to treat Obstructive Sleep Apnea. It is indicated for a wide swath of the patient population including bruxers, people with significant opening, and those with extensive protrusive ranges of motion. I’ve always felt that Herbst arms have been the “weak link” because they break, they don’t maintain position over time, and it’s been mind-numbingly difficult to accurately titrate the bilateral arms.

It makes telemedicine appointments much easier with…the measurement scale

Recently, Whole You™ offered a redesigned Herbst arm called the Respire Pink AT™ (Advanced Titration). I participated in their beta test and below are some of my experiences with this new game-changing innovation.

• Arms positioned parallel to the plane of occlusion. My experience is that this position reduces the vertical opening of the mandible requiring less use of elastics to maintain lip closure and promote nasal breathing. This positioning also places the connecting screws such that they do not rub the commissure of the lips or irritate the buccal mucosa of the cheeks. It might not seem like a big deal but it is.

• Rear access in the arm for insertion of new titration key. Both arms are adjusted in the same direction without removing and reinserting the key, which has a large, easy to grasp handle. This makes the Respire Pink AT™ arm less awkward and much easier to adjust than the traditional Herbst arms.

The special titration key fits deeply and

Barry Chase, DDS, is the founder of Chase Dental SleepCare, a private practice with multiple locations in the NY Metropolitan area dedicated to dental sleep medicine. Dr. Chase is a graduate of Georgetown Dental School, and a Diplomate to the American Board of Dental Sleep Medicine.

He is on the medical staff of Mt. Sinai Hospital, NYC and St. John’s Riverside Hospital in Yonkers, NY, as well as a Clinical Associate Professor of Dental Sleep Medicine, Stony Brook University and a member of the Board of the Respiratory Care and Polysomnography programs at the Stony Brook Health Technology School.

34 DSP | Winter 2020

securely into the arm. Overall, the adjustments are a tremendous improvement over the old style Herbst arms.

• Visual measurement scale on the arm.

Generally, I do not give the advancement tool to the patient so I can appropriately advance and record the adjustment.

Recording the advancement is now much more accurate. I always found it annoying and distracting to count the turns as I inserted and removed the little metal keys to make adjustments. It makes telemedicine appointments much easier with the visual indicators of the measurement scale.

• 7 mm total advancement with only 4 turns for 1mm. The Respire Pink AT™ allows a total of 7mm of protrusion. This means I can request the lab to preset the arm at +1 mm, which allows me to reduce the mandibular position upon insert if needed, and still offer 6mm of additional advancement. This results in fewer resets and less likelihood of being overly aggressive with starting positions.

• Advancements allow for stress-free adjustment virtually or chairside. In the new world of dental telemedicine, the Respire Pink AT™ arm now makes it possible and easier for patients to adjust the device, which can be guided by the dentist more accurately using the measurement scale on the arm. The arms move the same way on each side which makes it more intuitive for the patient.

The measurement scale depicts exactly what position the patient is in, and the new key makes it much easier to ajust the device, making it ideal for telemedicine.

The Respire Pink AT™ has now become my go-to when ordering Herbst oral appliances. Overall patient comfort is improved, horizontal adjustments are easier and more precisely calibrated, and it gives me extra adjustment capacity compared to the traditional pin-in-the-cylinder styles. I highly recommend trying the Respire Pink AT™ on your next few Herbst orders. I am confident you will find it a vast improvement and a welcomed innovation.

CLINICALfocus

Breathing Dysfunction and Head Posture

by Theodore R Belfor, DDS, and Michal Niedzielski, PT, PRC

M

uch attention has been given to blue light’s deleterious effects on sleep. Screen time’s negative impact isn’t limited to blue light though. Today’s over-reliance on cell phones, tablets, and computers contributes to a forward head posture which can affect breathing. Additionally, forward head posture should be viewed as an occupational hazard for dentists while treating patients.

What is FHP?

Forward head posture (FHP) is defined as​ forward translation of the cervical vertebrae and hyperextension of the upper cervical vertebrae​.​​Cervical straightening is when there are changes from lordosis, a correct curvature​ in a cervical spine,​ towards kyphosis (a reverse curvature). (See Fig. 1 and Fig. 2) However, there is a broader problem – inefficient respiration as a result of FHP. Dentists bring their heads forward and down to work with patients, similar to the posture many people exhibit when looking at a computer or cell phone screen. In a ​habitual FHP, the chin ultimately rises to bring vision to the horizon. When we bring the chin parallel to the ground, this causes a posterior cranial rotation, resulting in upper vertebrae

Figure 1: Correct head posture – upper cervic​al vertebra flexion, midcervical​ extension, and lower cervical flexion.

Figure 2: Reverse cervical spine occurs when the dentist is treating a patient – upper cervical flexion and lower cervical extension (left) and hyperextension of the upper cervical vertebrae and forward translation of the cervical vertebrae (right).

hyperextension, midcervical flexion​, ​and lower cervical extension. L​ooking down and focusing on small objects such as teeth, the eyes may begin to strain. Continuous over-convergence of the eyes may strain the extraocular and ciliary musculature tensing the eyes’ lenses so that small objects are in focus. This prolonged, slouched position increases back, neck, head, and eye tension as well as affecting respiration and digestion.1,2​ The shape of the thorax is significantly changed by FHP. It causes expansion of the upper thorax and contraction of the lower thorax. Therefore, ​impairment​ to respiratory function can be explained by the restriction of ​the​ thoracic motion during respiration caused by this characteristic thoracic shape resulting from FHP.3​ ​Because of this pattern, many of us will change the direction of airflow, from vertical, which is widening the lower chest​ to diagonal resulting in overuse of the neck and shoulder complexes and masticatory musculature. This also causes stomach distention and lower back compression. Breath holding is commonly observed with this pattern and recently the term “email apnea” was coined by former Apple executive Linda Stone​.​4

Pay Close Attention to Your Breathing When Examining or Treating Patients FHP stretches the tongue which slides into the airway and compromises breathing.

Evolving a smaller maxilla, modern humans have less room for the tongue on the roof of the mouth and the tongue has nowhere to go but down the throat. This obstructs and pressurizes the airway which facilitates even more FHP in order to improve volume and velocity of passing air.

Proper breathing is done by using your abdominal muscles. Dentists should be aware that the forward head posture and body position they assume while treating patients makes it difficult to breathe correctly because abdominal muscles are lengthened.

As a result, the upper chest and neck muscles are tasked to assist in breathing. These DentalSleepPractice.com

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CLINICALfocus

Figure 3: Cranial Cervical Extension and FHP

morphological changes can res​ult in improper breathing, predominantly with the upper chest and not the abdomen. This can overly tax muscles such as the scalene, sternocleidomastoid, and upper trapezius and may result in neck pain and headaches​. ​FHP causes expansion of the upper anterior thorax and contraction of the lower posterior thorax, and these changes cause decreased respiratory function, as well as sympathetic dominance.​ 5 ​This not only causes us to expend more energy than we need to, but it also tightens up compensatory muscles, and still provides a smaller volume of air than does expansion of lower posterior thorax during breathing.

Why is the quality and volume compromised? Because many of our lung’s alveoli lie in the lower posterior portions of the lungs​.

FHP is one of the greatest contributing factors to neck pain​​and causes a muscle imbalance.6 Muscle imbalance can be described as the respective inequality between the antagonist and agonist. Equilibrium is necessary for normal muscle movement. Imbalance will manifest in ​one group being overactive or too

Theodore R. Belfor, DDS, is a graduate of New York University College of Dentistry, a Senior Certified Instructor for the International Association for Orthodontics (IAO) and has been in private practice for more than 40 years. Since 2001, Dr. Belfor has specialized in patient treatment with the Homeoblock™ orthopedic/orthodontic appliance designed with the Unilateral Bite Block technology®, for face and airway development in adults. Dr. Belfor has been lecturing, teaching and training dentists with the Homeoblock™ and his unique diagnostic protocol for more than 18 years worldwide. His work is devoted to understanding the causes of sleep and breathing disorders through individual patient craniofacial analysis. Dr. Belfor has been published in numerous journals. He can be reached through his site at drtheodorebelfor.com.

Michal Niedzielski, PT, PRC, graduated with a Master’s Degree in Physical Therapy from the Academy of Physical Education in Warsaw, Poland in 1992. Prior to starting the Comprehensive Physical Therapy (former Physical Therapy Center of Horseheads) in 1996 with Joyce Wasserman, Michal worked as a physical therapist for the Arnot Ogden Medical Center. In 2007, Michal earned the designation of being Postural Restoration Certified (PRC). He then returned to Poland to introduce the concepts of Postural Restoration to hundreds of students and physiotherapists. He lectured and taught courses in Poland at several universities. Michal currently sees patients whose conditions range from slight compensations with minor aches to a serious pathology with incapacitating pain. He can be reached through his site at comphysicaltherapy.us.

36 DSP | Winter 2020

tight and the other underactive or too loose.​ As the head moves forward, musculature that attaches from the upper cervical and occipital region and inserts into the shoulder girdle, namely the upper trapezius and the sternocleidomastoid (SCM), will be in a shortened length-tension relationship. In contrast to their antagonists, the​ ​supra/infrahyoid group which will be in a lengthened length-tension relationship. Head forward posture relaxes the supra/infra hyoid complex and the genioglossus and hyoglossus. Over-recruitment of the upper trapezius will be a new norm.

To maintain vision and a vestibular system parallel to the horizon, a strong reflexive alliance with the anterior temporalis, masseter, and pterygoid musculature is formed. Here is where we can lose pharyngeal airway tone.

The suprahyoid/infrahyoid muscles maintain the tone of the pharyngeal airway. This is bad news for cell phone users, gamers, avid readers, and dentists.

Dentists should be aware that these cervical-masticatory issues can result in improper breathing and are related to obstructive sleep apnea (OSA).​​A typical severe OSA male patient portrays some cephalometric characteristics observed in Cranial Cervical Extension and FHP (Fig. 3).

There is a Class ll mandible which brings the tongue into the airway. The tongue then lifts the soft palate to obstruct the oropharynx. When the tongue is in the airway the head comes forward to allow for better breathing. The upper trapezius and the SCM muscles tighten to support the head and their antagonist muscles, the suprahyoid muscles, relax. This results in a low hyoid bone position, a biomarker for sleep apnea.

1.

2.

3.

4.

5.

6.

Colombo, S Joy, M., Mason, L, Peper, E, Harvey, R, & Booiman, A (2017). “Posture Change Feedback Training and its Effect on Health. “Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback, 42(2), 147.

Devi, R R, Lakshmi, VV, & Devi, MG (2018). “Prevalence of discomfort and visual strain due to use of the laptops among college going students in Hyderabad. “Journal of Scientific Research & Reports, 20(4), 1-5.

Koseki T, Kakizaki F, Hyashi S, Nishida N, Itoh M. Effect of forward head posture on thoracic shape and respiratory function. ​J Phys Ther Sci. 2019 Jan;31(1):63-68.​doi: Stone L, Just breathe: Building the case for email apnea Huffington Post Feb. 2008 Koseki T, Kakizaki F, Hyashi S, Nishida N, Itoh M. Effect of forward head posture on thoracic shape and respiratory function. J. Phys Ther Sci 28: 128-131, 2016 Dae-Hyun Kim​,a ​Chang-Ju Kim​,b,* and ​Sung-Min Son​b. Neck Pain in Adults with Forward Head Posture: Effects of Craniovertebral Angle and Cervical Range of Motion ​Osong Public Health Res Perspect​. 2018 Dec; 9(6)

THE FLAT PLANE SPLINT HAS BEEN USED SINCE 1901.

IT’S TIME TO ADVANCE.

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

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CONTINUING education

ACEs, Integrative Medicine, and the Mind Body Connection Why Dental Sleep Practitioners Must Take a Seat at This Table

by Sunita Merriman, DDS

“W

hat is spoken of as a clinical picture is not just a photograph of a sick man in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears.

Now all of this background of sickness which bears so strongly on the symptomatology is liable to be lost sight of in the hospital.”1

Educational Aims

Patients enter dental sleep practices with issues that can complicate treatment and which may not be evident upon physical exam or radiograph. Emotional trauma may adversely impact sleep quality, treatment compliance, and overall health. Understanding how to identify these issues and associated comorbidities, discuss them with patients, refer to mental health professionals when appropriate, and recognize what impact they’re having on treatment outcomes is crucial to providing comprehensive integrative care.

Expected Outcomes

Dental Sleep Practice subscribers can answer the CE questions online at dentalsleeppractice.com/ce-articles to earn 2 hours of CE from reading the article. Correctly answering the questions will exhibit the reader will: 1. Define Adverse Childhood Experiences (ACEs) 2. Understand the relationship between ACEs, sleep disordered breathing (SDB), and potential health outcomes 3. Recognize paths to broach mental health concerns with dental patients 4. Identify how depression and ACEs may affect SDB treatment acceptance or adherence 5. Possess the ability to incorporate an ACE screening protocol into the dental practice

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Although penned in 1927, if Dr. Francis W. Peabody sat at his desk today to review those words from his landmark article “The Care of The Patient,” it is very likely he would list “childhood history” to what he considered to be major components of an “impressionistic painting” of the clinical picture of a patient.

In addition to the impact and consequences of sleep deficiency and sleep disorders on adults, Pediatric Sleep Disordered Breathing has captured our attention, and continues, rightfully so, to be the subject of multidisciplinary research. A Google search of Pediatric Sleep Disordered Breathing on any given day yields over 670,000 results.

This bodes well for our society on many levels. But SDB can relate to childhood in a different way as we understand it.

Childhood Trauma or ACEs, Adverse Childhood Experiences

According to the Adverse Childhood Experiences (ACE) Study, ACE’s are potentially traumatic events that occur in childhood (017 years) which could include experiencing violence, abuse, or neglect, witnessing violence in the home or community or having

CONTINUING education a family member attempt or die by suicide.2 The investigators of this landmark study also found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Prevalence of ACEs

According to the National Center for Injury Prevention and Control, Division of Violence Prevention, ACE’s are common, and their effects can accumulate over time. 61% of adults had at least one ACE and 16% had 4 or more.

Females and several racial/ethnic minority groups were at greater risk for experiencing 4 or more ACEs.

What is Your ACE Score?

Most readers know what our weight, blood pressure, cholesterol, AHI, and and blood sugar levels are. We should also know our ACE score.

This questionnaire can be offered to our patients when we suspect that their medical, social, and psychological presentation suggests a history of childhood trauma.

It’s best to introduce the subject conversationally in a neutral tone, very much like you would ask their permission to do an oral examination at a dental appointment. It may be more sensitive of you to let them know that it’s okay for them to just disclose to you how many ACEs they feel apply to them, instead of which specific ones do.

ACEs and Their Long-term Impact on Health in Adulthood

Individuals with at least 4 ACEs were at increased risk of all negative health outcomes compared with those with no ACEs.3

Figure 1: Types of ACES. Source: Merrick, M.T., Ford, D.C., Ports, K. A., Guinn, A. S. (2018). Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatrics, 172(11), 1038-1044.

61% of adults had at least one Adverse Childhood Experience

Figure 2: How Common Are ACES. Source: Centers for Disease Control and Prevention, Kaiser Permanente. The ACE Study Survey Data [Unpublished Data]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2016.

Sunita Merriman, DDS, graduated from New York University, College of Dentistry with honors in 1994. This was followed by a two-year General Practice Residency (1994-1996) at Long Island Jewish Medical Center in New Hyde Park, New York and a mini-residency in Sleep Medicine and Dentistry in 2016 at the American Academy of Craniofacial Pain. She is the founder of the New Jersey Dental Sleep Medicine Center, NJDSMC in Westfield, New Jersey. Dr. Merriman is a Diplomate of both the American Board of Dental Sleep Medicine and the American Board of Craniofacial Dental Sleep Medicine. She is involved with presentations at the JFK Medical Center Sleep Fellowship Program for medical specialists who are training to be Sleep Specialists and is on staff at Overlook Medical Center in Summit, NJ. Dr. Merriman is also a poet and a writer. Her first book of poetry, “Stripping – My Fight to Find Me” is available at her website www.SunitaMerriman.com and Amazon. It is also available, as narrated by her, on Audible. She writes a blog at www.SelfLoveSelfCareFirst.com and is a passionate advocate of those who suffer from childhood trauma and mental illness.

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CONTINUING education Exposure to ACEs can evoke toxic stress responses, immediate or long term physiologic and psychologic impacts by altering gene expression, brain connectivity and function,

Prior to your 18th birthday: 1.

Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

No___ If Yes, enter 1 __ 2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?

No___ If Yes, enter 1 __ 3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?

No___ If Yes, enter 1 __ 4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?

No___ If Yes, enter 1 __ 5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

No___ If Yes, enter 1 __ 6. Were your parents ever separated or divorced?

No___ If Yes, enter 1 __ 7. Was your mother or stepmother:

Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

No___ If Yes, enter 1 __ 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

No___ If Yes, enter 1 __ 9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

No___ If Yes, enter 1 __ 10. Did a household member go to prison?

No___ If Yes, enter 1 __ Now add up your “Yes” answers: ____ This is your ACE Score.

Figure 3: ACES Study questionnaire. Source: ACEs Too High News, https://acestoohigh.com/

Figure 4: Age-adjusted death rates for the 10 leading causes of death: United States, 2016 and 2017.

Source: NCHS, National Vital Statistics System, Mortality

40 DSP | Winter 2020

immune system function, and organ function.4 There is a dose response relationship between ACEs and health outcomes. ACEs impact us through repeated stress activation, which causes our natural stress adaptive system to become maladaptive. The current understanding of the biology of stress on the brain informs us of our physiological response to the activation of the hypothalamic-pituitary-adrenocortical axis and the sympathetic-adrenomedullary system and resulting release of stress hormones. Children who suffer from ACEs experience toxic levels of stress, and dysregulation of their response to this stress, which leads to not only shortterm changes in observable behavior but also less outwardly visible permanent changes in brain structure and function. These biological disruptions associated with ACEs are linked to greater risk for a variety of chronic diseases well into adulthood.5 At least five of the 10 leading causes of death in the US (cardiovascular disease, diabetes, emphysema, cancer, and suicide) are associated with exposure to ACEs and have a graded relationship between ACE scores and health outcomes.6 Preventing ACEs could potentially translate to a reduction of up to 1.9 million cases of coronary heart disease, 2.5 million cases of obesity, and 21 million cases of depression.7

ACEs and Their Entry into Mainstream Conversation

ACEs are not only occupying pages in medical journals but are now also appearing in mainstream media. Dr. Nadine Burke Harris’s TED talk “How childhood trauma affects health across a lifetime” ignited interest among both the public and medical professionals regarding the hidden nightmare of ACEs and their impact on adult health and mortality. It has been viewed over 7.6 million times since it first aired in 2014.8 The sad fact is that widespread attention to ACEs came 16 years after the ACEs study

by The Kaiser Institute and the CDC. “Their pain is real – and for patients with mystery illnesses, help is coming from an unexpected source” reads the title of a now highly referenced article in The Globe and Mail written by Erin Anderssen in December 2018.9 It sheds light on a psychotherapy technique called Intensive Short-Term Dynamic Psychotherapy (ISTDP) that has been shown to effectively treat, among many other conditions and

CONTINUING education disorders, the consequences of interruptions and trauma to human attachments and other childhood trauma.

Ms. Anderssen quotes professor, psychiatrist, and leading ISTDP researcher, Dr. Allan Abbass, “Shake things up, and what you find, in as many as 95% of cases, is a childhood story, one that’s been buried deep, carried like a malignant cell into adulthood, until it emerges as headaches or stomach pain or any number of physical ailments.”10

How do ACEs Affect the Realm of Dental Sleep Medicine?

In addition to the direct association of ACEs with sleep disorders, there are many other ways they impact the scope of practice of Dental Sleep Medicine as we will explore in this article.11 ACEs have been associated with self-reported sleep disturbances in adulthood. Additionally, the ACE score had a graded relationship to these sleep disturbances.12 A systematic review conducted by the Department of Epidemiology at the Harvard T.H Chan School of Public Health, and Harvard Medical School in Boston, Massachusetts, USA noted that there is a growing body of scientific knowledge that points to an association between ACEs and multiple sleep disorders in adulthood.13

OSA and Comorbidities

Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs.23 Even though there still remains a lack of consensus in the acceptance of an internationally recognized definition and conceptualization of comorbidity, there has been a consistent increase in interest in the role played by comorbidities in OSA as evident by the rising number of publications on this topic.24 OSA patients show a high level of prevalence of comorbidities compared to other sleep disorders. In addition, as a recent study from Taiwan confirmed, OSA patients showed a high prevalence of cardiovascular diseases, respiratory diseases, and metabolic disorders.25 Many other co morbid disorders were also identified such as anxiety, insomnia, de-

Obstructive Sleep Apnea and It’s Treatment

Obstructive sleep apnea (OSA) is a highly prevalent disorder, characterized by recurrent episodes of upper airway obstruction occurring during sleep. It’s associated with recurrent cycles of desaturation and re-oxygenation, sympathetic over-activity and intra-thoracic pressure changes leading to fragmentation of sleep.14 Consequently, symptoms of OSA may present as excessive daytime sleepiness, forgetfulness, impaired concentration and attention, personality changes, and morning headaches.15 Untreated, OSA has many potential consequences and adverse medical associations including an increased risk of motor vehicle accidents, cardiovascular morbidity, and all-cause mortality.16,17 Sleep disorders contribute to lost work productivity and absenteeism but also lead to poor health outcomes such as diabetes, obesity, hypertension, depression, occupational injuries, and premature mortality.18-22

Figure 5: Retrieval of references by searching PubMed for “obstructive sleep apnea” and comorbidities, 9 Jan 2019. Source: Bonsignore et al. Multidisciplinary Respiratory Medicine (2019) 14:8, Reprinted with author’s permission.

Figure 6: Differently from other common sleep disorders, 80% of patients with obstructive sleep apnea (OSA) show multiple comorbidities: RLS (restless leg syndrome). Source: Bonsignore et al.

Multidisciplinary Respiratory Medicine (2019) 14:8, Reprinted with author’s permission.

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CONTINUING education pression, gastroesophageal reflux, and chronic liver disease.

Given the high undiagnosed rate of OSA in the general population, its close relationship to common coexisting diseases may provide a way to recognize it.

Obstructive Sleep Apnea, Sleep Disturbances, and Depression

A recent study of the National Health and Nutritional Examination Survey concluded that frequent snorting or stopping breathing during sleep was associated with higher prevalence of probable major depression regardless of factors like weight, age, sex or race.26 High rates of depression have always been found among patients with OSA. Sleep complaints and depression are bidirectionally related with as many as 90% of patients with depression having complaints of patients regarding their sleep quality.27,28 undergoing a major About 75% of patients undergoing a depressive episode will major depressive episode will experience experience insomnia insomnia. Depression is also overrepresented in individuals with sleep disorders.

Individuals with OSA may meet the criteria of being diagnosed with depression in occurrences as high as 24%-58%.29,30

75%

COMISA (Co-Morbid Insomnia and Obstructive Sleep Apnea) is in Your Dental Sleep Practice Individually, Obstructive Sleep Apnea and Insomnia are the two most common sleep disorders. Insomnia is defined as a persistent difficulty with sleep initiation (DIS), duration, consoli-

dation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment.31 Together, they afflict an even larger population. Researcher Alexander Sweetman and his colleagues note that both OSA and insomnia include nocturnal sleep disturbances and impairments to daytime functioning.32 It was in 1973 when Christian Guilleminault and colleagues first documented the co-occurrence of insomnia and sleep apnea. “A new clinical syndrome, sleep apnea associated with insomnia, has been characterized. Repeated episodes of apnea occur during sleep. Onset of respiration is associated with general arousal and often complete awakening, with a resultant loss of sleep. An important clinical implication is that patients complaining only of insomnia may be suffering from this syndrome.”33 There is a renewed interest in COMISA as is evident by the number of publications on the topic in recent years. 30-50% of OSA patients report co-morbid insomnia symptoms, which reduces acceptance and use of CPAP therapy. This is an excellent opportunity for oral appliance therapy to be considered when appropriate for a patient.

Insomnia is a complex condition with a wide variety of etiologies. It is often self-treated by patients with OTC sleep aides which masks and helps avoid examination of the underlying issues. The effectiveness of CBTI (cognitive behavior therapy for insomnia) on the other hand is well-documented and is now the American College of Physicians’ first-line recommended treatment for insomnia.34 For those of us treating patients who suffer from COMISA or Insomnia, there are many challenges to getting our patients CBTI, directly impacting our ability to successfully relieve their symptoms.35

Important Considerations for Dental Sleep Medicine Practitioners

Figure 7: History of research in co-morbid insomnia and sleep apnea, including Guilleminault and colleague's1973 article, and a lack of widespread research attention until two articles by Lichstein and colleagues (1999) and Krakow and colleagues (2001). Source: Co-Morbid Insomnia and Sleep Apnea (COMISA): Prevalence, Consequences, Methodological Considerations, and Recent Randomized Controlled Trials Brain Sci. 2019, 9, 371 - With permission of author.

42 DSP | Winter 2020

Any dentist who has provided oral appliance therapy to a patient diagnosed with OSA can relate to the frustration of achieving less than optimal results, often due to underlying comorbidities that are complicating treatment.36 Many of the comorbidities of OSA are conditions that also present in adults who have a score of 4 ACEs or more. Given this information, a diagnosis of OSA occurring along with one or more of its identified highly prevalent comorbidities may provide a way to recognize

CONTINUING education an opportunity to screen for a history of ACEs in an adult patient.

We must get comfortable asking our patients about their mental health and childhood as the starting point of our health history inquiries.

What if there are undiagnosed ACEs? These can add additional layers of complexity to the case, resulting in poor management and possibly even worsening of the patient’s condition.

How will a mandibular advancement device succeed against a backdrop of commonly occurring musculoskeletal pain reported by 11-29% of the population?37 50-80% of chronic pain patients complain of poor sleep.

The sleep of middle-aged patients with chronic pain is comparable to that of insomnia patients.38 Many of this significant segment of our population who suffer from chronic pain do so as a result of the creation of neural pathways that are in response to trauma suffered in childhood or even as adults.39 Back pain, myofascial pain, fibromyalgia, and rheumatoid pain are the most frequent conditions that lead to chronic pain. They are joined by chest pain, gastrointestinal issues, headaches, migraine, memory difficulties, muscle weakness, and other mind body problems as difficulties that are often co-morbid with anxiety, depression, personality issues, and/or trauma.

Many such physical and somatic symptoms are associated with underlying unconscious processes that sabotage any chances of success at alleviating symptoms of OSA. Unless these patients are treated for their mental, emotional, and psychological injuries and issues, their physical disorders persist and interfere in the resolution of their sleep disorders.

So, we must expand our collaborative relationship circle to include mental healthcare professionals, trauma informed practitioners and integrative care physicians. These relationships are vital and potential bidirectional patient referral sources as well as opportunities to exchange knowledge. CPAP tolerance amongst PTSD patients and those who have suffered different types of trauma have been suggested to be low, so oral appliance therapy for OSA would be a great addition to their care.40 Psychophysiological disorders are slowly gaining recognition in the general medical community as having underlying psychological sources of origin for the medical conditions in disabled workers who suffer from chronic pain and other conditions.

These individuals often have associated sleep disorders, and when they show up in our offices, present a severe challenge to successfully treating them if we do not take their total health into account; both physical and mental.

Conversely, when they seek care from integrative medicine practitioners, due to the high prevalence of OSA associated with these disorders, it would be prudent for them to refer their patients to be diagnosed and treated for OSA when appropriate. Having a Dental Sleep Practitioner on their team would be of great benefit to their patients.

A Case Study

A few years ago, a 67 year- old female presented to me complaining of “Fatigue, morning headaches, anxiety, depression, witnessed cessation of breathing by my 50-80% of chronic bed partner, frequent snoring, gasping for pain patients breath and nighttime choking spells that complain of wake me up from my sleep” Her medical history was significant for poor sleep. acid reflux, autoimmune disorder, high blood pressure, chronic fatigue, chronic pain, depression, difficulty sleeping, fibromyalgia, hypertension, osteoporosis and sleep apnea.

Her accompanying HST report showed her AHI to be 4.1 and her RDI to be 46.2.

The patient was referred to me by her sleep physician due to her intolerance to CPAP therapy.41 After a thorough history and clinical evaluation, I realized that her complaints of insomnia had not been addressed and recommended she see a psychologist for CBT-I first. I then fabricated a custom oral appliance for her.42 After insertion of the appliance and titration instructions, the patient had little success with the relief of her symptoms other than snoring.

She requested multiple appointments with me for complaints of areas that ‘burned’ and ‘hurt’ due to appliance wear, bite issues, and difficulty tolerating the appliance for more than a few consecutive nights. For each complaint, there were no corresponding visible clinical presentations to treat or adjust.

These visits were starting to become frustrating for both of us. I could also see the increasing helplessness that her spouse felt as well. One day her husband mentioned that she just wasn’t getting better, even though they had seen 23 doctors in the previous 2 years.

Having developed a sincere relationship with my patient and her husband, I had learnt DentalSleepPractice.com

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CONTINUING education that there had been some recent tragic events in their family, in addition to her having a difficult childhood. Carefully reviewing the nature of her medical complaints, I decided to put emphasis on my conceptualization and understanding of my patient’s emotional state, instead of her diagnosis of OSA. I told them I thought that she may benefit from a consult with a mental health professional. They followed up on my referral to a psychiatrist with urgency.

I heard from my patient’s husband some months later. He told me that by the time they were able to see a psychiatrist/psychologist, she had deteriorated to the point where she had to be hospitalized for major depressive disorder. He could not thank me enough for spotting “the source of her problems that was missed by so many.”

This case did not end with me reducing a patient’s AHI below 5, but I felt it was a success. I suspect Dr. Peabody would have concurred.

Dental Sleep Medicine must look below the tip of the iceberg of our OSA patients, by not only focusing on their chief complaints, AHI, and oxygen saturation, but by being a part of the sweeping movement of the recognition and acknowledgement of their mind-body connection. Otherwise, we run the risk of being known as mere appliance makers.

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Legal disclaimer: Course expires 3 years after publication date. The CE provider uses reasonable care in selecting and providing accurate content.The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

n To receive credit: Go online to dentalsleeppractice.com/ce-articles, click on the article, then click on the take quiz button, register/login to CEZoom, and enter your test answers To provide feedback on this article and CE, email us at education@medmarkmedia.com

ACEs, Integrative Medicine, and the Mind Body Connection

by Sunita Merriman, DDS

1. ACE is an acronym for _________ a. Apnea Cardiac Evaluation b. Adverse Childhood Experiences c. Altimeter Coordinate Exercise d. Apneic Covid Exhibition

6. 30-50% of OSA patients report co-morbid insomnia symptoms, which may reduce acceptance and/or adherence to CPAP therapy. a. True b. False

2. According to the National Center for Injury Prevention and Control, Division of Violence Prevention, what percentage of the population had 4 or more ACEs? a. 5% b. 16% c. 39% d. 52%

7. What percentage of people suffering from a major depressive episode will experience insomnia? a. 35% b. 50% c. 75% d. 92%

3. Evidence exists of an association between ACEs and multiple sleep disorders. a. True b. False 4. In what year did Christian Guilleminault and his colleagues first document the co-occurrence of insomnia and sleep apnea? a. 1969 b. 1973 c. 1981 d. None of the above 5. What percentage of chronic pain patients complain of poor sleep? a. 20 – 40% b. 50 – 80% c. 70 – 90% d. 96%

8. A recent study of the National Health and Nutritional Examination Survey concluded that frequent snorting or cessation of breathing during sleep was associated with higher prevalence of ____________ a. Inflammatory arthritis such as gout b. Probable major depression c. Irritable bowel syndrome d. None of the above 9. According to the Adverse Childhood Experiences (ACE) Study, examples of ACEs include __________ a. Experiencing violence b. Abuse c. Witnessing violence in the home d. All of the above 10. The 2 most common sleep disorders are ___________ a. Insomnia and sleep apnea b. Insomnia and periodic limb movement disorder c. Sleep apnea and SARS d. Central sleep apnea and obstructive sleep apnea DentalSleepPractice.com

45

LASERfocus

LightScalpel Functional Frenectomies and Frenuloplasties: A Partial Literature Review

by Peter Vitruk, PhD, MInstP, CPhys

F

irst described in 2016, the LightScalpel Functional Releases include the following steps:1-4 1. Pre-surgical Oro-Myofunctional Therapy (OMT); 2. LightScalpel laser release, combined with the intra-operative Functional Assessment; 3. Post-surgical OMT exercise program to ensure long-lasting Functional Results.

The goal of a Functional Frenectomy in children, adolescents and adults is to release the restricted frena, i.e. Tethered Oral Tissues (TOTs) and to restore, with the help of mandatory pre- and post-frenectomy Oro-Myofunctional Therapy (OMT), the mobility and functionality of tongue and lips for optimal breathing, speech, chewing, swallow, and posture. Besides the surgeon, a Functional Frenectomy involves a team trained in myofunctional (or physical, craniosacral, osteopathic, or chiropractic) therapies.1-4 Post-frenectomy, the surgical site is healed by second intention with mandatory OMT exercises.

During Laser Frenuloplasty, sutures are placed after the laser release of restrictions.3 A properly performed Functional Frenuloplasty results in as high as “87% rate of improvement in quality of life through amelioration of mouth breathing (78.4%), snoring (72.9%), clenching (91.0%), and/or myofascial tension (77.5%).”5

Figure 1: LightScalpel Functional Frenuloplasty performed by Dr. Soroush Zaghi, MD at The Breathe Institute. Surgical video is available at https://www.youtube.com/ watch?v=7WFZ-6LuN1k&list=PL4ROT89t1sVtyFCoK6Gls4E0xqKlSOvbm&index=5

46 DSP | Winter 2020

Why LightScalpel CO2 laser?

Not all lasers are equally good at vaporizing, i.e., ablating or cutting and coagulating the blood vessels in the soft tissue, which is critical for fast and efficient frenectomies illustrated in Figures 1 and 2. Typically, tongue-tie revision with the CO2 laser does not involve suturing of the wound, and usually there is no scar. Minimal to no scarring is critical for post-operative OMT exercises that involve the tongue.

Figure 3 demonstrates the difference in the absorption spectra for the main soft tissue chromophores for different laser wavelengths and explains the following benefits of LightScalpel 10,600 nm CO2 lasers for oral soft tissue surgery:1-4 • Approximately 1,000 times greater photo-thermal cutting efficiency relative to dental diodes, and in approximately 10 times greater photo-thermal coagulation/hemostasis depth relative to erbium lasers; • Close match between the coagulation depth of the CO2 laser (approx.

Figure 2: LightScalpel Functional Frenectomy performed by Dr. Leonard Kundel, DMD. Surgical video is available at https://www. youtube.com/watch?v=COJPHAH_F78&list=PL4ROT89t1sVtyFCoK6Gls4E0xqKlSOvbm&index=13

LASERfocus

A properly performed Functional Frenuloplasty results in as high as

7 % 8

rate of improvement in quality of life

50 μm for SuperPulse mode and 100200 μm for non-SuperPulse) and the blood capillary diameters (20-40 μm).6 This distinguishes CO2 lasers from erbium lasers and provides for instant and efficient hemostasis and coagulation during high-speed ablation or cutting of the vascular tissues.

The CO2 laser ablates tissue while coagulating small blood and lymphatic vasculature. It provides improved visibility of the surgical field and therefore enables more precise and accurate tissue removal; • Minimal post-operative edema, pain and discomfort; due to the intraoperative closure of lymphatic vessels on the margins of the CO2 laser incision. With CO2 laser frenectomy, patients report less post-operative pain and discomfort than with the scalpel.1-4

Depth of LightScalpel Laser Incision

During laser incisions, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a cold steel blade. Greater laser fluence (i.e., power density times the duration it applied to the target) results in greater depth and rate of soft tissue removal. For short pulse steady state ablation conditions, the ablation depth is: A (E – Eth)/Eth, where A is the absorption depth and Eth is the ablation threshold fluence from Figure 3, and E is the fluence delivered to the tissue.1-4 For repetitive pulses that are scanned across the soft tissue, the depth of incision is proportional to laser average power, and is inversely proportional to focal spot diameter and the surgeon’s hand speed. For clinical cases illustrated in Figures 1 and 2, the LightScalpel CO2 laser was set to 2 W Non-SuperPulse, and gated at 20 Hz, 40-60% duty cycle, 0.8-1.2 W average power. A handpiece with a 0.25 mm focal spot diameter produces 300-400 μm depth shallow incisions at a 3-5 mm/sec hand speed.

Such shallow incisions, combined with shallow coagulation depth (100-200 μm), allow for excellent and progressive visualization of larger diameter blood vessels.4

Summary

Figure 3: Spectra of Absorption Coefficient, 1/cm, at histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2) in sub-epithelial oral soft tissue, and: Thermal Relaxation Time, TRT, msec; short pulse Ablation Threshold Fluence, Eth , J/cm2; and short pulse Photo-Thermal Coagulation Depth, H, mm. B is gingival blood vessel diameter. Logarithmic scales are in use. Graph courtesy of LightScalpel LLC.

The choice for the CO2 laser wavelength and pulsing settings is based upon its unique absorption coefficient by the water-rich soft-tissue. Decreased wound contraction combined with minimal lateral tissue damage, less traumatic surgery, less post-operative pain, precise control over the depth of incision, and excellent hemostatic ability make the LightScalpel CO2 laser a safe and efficient tool for Functional Frenectomies and Frenuloplasties.1-4 1.

2.

3.

Peter Vitruk, PhD, is a founder of the American Laser Study Club and LightScalpel, Inc. in Bothell, WA, and a member of The Institute of Physics, London, UK. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com

4.

5.

6.

48 DSP | Winter 2020

Fabbie P, Kundel L, Vitruk P. Tongue-Tie Functional Release.

Dent Sleep Practice. Winter 2016: 40-45.

Riek C, Bahnerth S, Vitruk P. CO2 Laser Functional Frenectomy.

Dent Sleep Practice. Spring 2019:34-36.

Mugno M, Erson T. A Team Approach to Functional Laser Frenuloplasty and Optimal Orofacial Function. Dent Sleep Pratice.

Fall 2019:48-52.

Geis M, Kundel L, Vitruk P. Functional Frenectomy (Osteopathically Guided). Dent Sleep Practice. Summer 2018:30-32.

Zaghi S, Valcu-Pinkerton S, Jabara M, Norouz-Knutsen L, Govardhan C; Moeller J, Sinkus V, Thorsen RS, Downing V, Camacho M, Yoon A, Hang WM, Hockel B, Guilleminault C, Liu SYC. Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. The Laryngoscope. 2019.

Vitruk P, Levine R. Hemostasis and Coagulation with Ablative Soft-Tissue Dental Lasers and Hot-Tip Devices. Inside Dentistry.

2016 Aug;12(8):37-42.

PRODUCTspotlight

Seeing is Believing by Samuel E. Cress, DDS

“C

BCT is useless in dental sleep because people don’t sleep sitting upright.”

“CBCT is a wasteful expensive piece of equipment that unnecessarily radiates my patients.”

You have probably heard these types of statements in lectures or on social media. Maybe you’ve even cast similar aspersions. I’d say it’s inarguable that a clearer understanding of the guest’s anatomical features for implant placement, endodontics, and dental sleep medicine (DSM) enables you to become a better clinician.

In my experience, the data provided from 3D provide the best view and empowers me to provide the highest quality of care for my guests.

When I embarked on my DSM journey in 2008, I owned a bustling general dentistry practice. After education, the first investment I made when delving into DSM was a CBCT unit. However, the equipment had myriad uses unrelated to sleep. I used it for implant placement, endo, and ortho cases. It was a significant investment and though I used it for all those other procedures, I really paid for it in my sleep practice.

After providing oral appliance therapy (OAT) for over ten years, I recently launched a new journey by opening a practice dedicated entirely to the treatment of OSA and TMJ disorders. The standard of care in my practice is the use of CBCT to acquire data for evaluation of temporomandibular joints when treating pain and before treating any guests with OAT. I simply can’t imagine practicing without it and once again, when outfitting the new office, I went with a CBCT unit from Dentsply Sirona; this time in the form of the Axeos. It’s vitally important to capture pristine images of the nasal cavities down to the hypopharynx. Acquiring an excellent view of the individual’s condylar relationship is key in selecting and prescribing the appropriate appliance to treat OSA. Personally, I use the Axeos 17x13 cm field of view (FoV). The versatility of this 2D/3D unit guarantees that I efficiently capture everything I need to see.

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

50 DSP | Winter 2020

While I’ve opted for the largest FoV, the Axeos 3D Imaging System is flexible to take smaller FoV in 5x5.5 cm, 8x8 cm, and 11x10 cm. The Axeos captures the airway, complete dentition, including both temporomandibular joints and the cranial base in one simple pass. Its 2D/3D hybrid capability, convenient 2D programs including extraoral bitewings, HD, SD, LD 3D settings, along with metal artifact reducing software, makes Axeos the top 3D unit on the market. I’m no tech slouch but I’m not Bill Gates either and the Axeos is crazy intuitive. Its guest imaging assistant allowing for auto height adjustment and the patented auto positioner make this very easy to use. Axeos has been developed to embrace the ALARA (As Low As Reasonably Achievable) principle to allow for exceptional image quality at the lowest reasonable radiation dose. This negates any well-intentioned but misinformed concerns centered on radiation dosage.

The Axeos hardware is phenomenal but when paired with Dentsply Sirona’s SICAT Air software, a slew of new possibilities open up. The software gives a clear airway visualization and analysis which I use to more effectively convey to the guest what a typical airway volume should be and compare that with their own. This visualization helps guest more fully understand the concepts and importance in maintaining their airways. It eliminates much of the abstraction for guest which has dramatically increased my case acceptance.

The Axeos provides superior images, but what it really does is give me the clarity and confidence to do more. Better. Dentsply Sirona Axeos CBCT is the nucleus of digital workflow in my DSM practice.

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TEAMeffort

Less Calculus – More Sleep A Day in the Life of a Sleep Hygienist

by Gina Pepitone-Mattiello, RDH

A

day in my life as a dental sleep medicine hygienist makes my heart happy and helps me sleep better at night. For starters, I am not picking up a scaler or explorer anymore. Instead, my instruments are a pulse oximeter and sphygmomanometer. Days are filled following up with referrals from sleep centers, physicians, and the occasional internet surfer who discovers our practice online. No matter how they come to us, they are always seeking the same things – hope and a better night’s sleep.

I am working in a dental sleep medicine practice that manages sleep disordered breathing (SDB) with mandibular advancement devices (MAD), commonly known as oral appliances. Long story short (no, it really will be), this simply complex oral appliance saved my husband’s life and turned me into an airway advocate.

I call the night before a workday my “evening prep.” Prior to a patient visiting our practice, our sleep administrator obtains any pertinent medical records, sleep study results, clinical notes, and health insurance information. Each night I spend around an hour reviewing my patient records and explore their story. As I familiarize myself with my patient’s symptoms and medical history, I begin to understand why they are seeking help. Sometimes they just want refreshing sleep, occasionally they have nightmares of drowning, and in other instances they simply aim to make their partners happy; no one is exactly the same.

52 DSP | Winter 2020

Mornings begin with a team huddle. We discuss details of each patient including preferences of the referring physician, their sleep breathing disorder diagnosis, and their applicable medical benefits. Our administrative team is notified about any fees or additional records needed beforehand. Some are new patients already diagnosed with OSA while others suspect they may have sleep apnea.

When I meet a new patient for the first time, I mostly just listen. After we chat about their chief complaints and their goals for treatment, I explain the mechanism of Oral Appliance Therapy and how it may help them. I’ve found the Airhead Obstructive Sleep Apnea Demonstration Model (TMJ Technologies) to be wildly useful for this purpose. His mandible moves, the airway collapses, and it shows how an oral appliance maintains an open airway. This is always an eye-opener for patients – it’s almost like DSM show and tell!

We discuss their symptoms and I help them connect the dots regarding how those symptoms are related to their sleep breathing disorder. Dedicating the time to explain how the body functions and what the toll of poor sleep is on their physical and mental well-being frequently leads to an “aha” moment.

This is usually the first time anyone has really carved out the time to listen to them and explain this information in relatable terms.

I have several MAD samples that I use to further explain how oral appliances work. After that, I begin the dental sleep clinical exam.

At this point, I put my “dental hat” back on

TEAMeffort and chart the teeth, perform a TMJ evaluation, document anatomical features including tongue size, Mallampati classification, and other general features present in the oral cavity. It’s very important that we identify any dental concerns precluding the patient from wearing an oral appliance. Additionally, a thorough oral exam can help guide the decision-making process about which appliance is best indicated for the patient. Many insurance payors also require this documentation.

Once all of the information is gathered, it is time for the sleep dentist to see the patient. They will confirm that the patient is a candidate for oral appliance therapy and the style of oral appliance is determined. Next I review medical insurance benefits with the patient and map the financial arrangements.

Then we take impressions. I take most of the impressions using a digital scanner although we occasionally take PVS impressions.

The bulk of my day is filled with appliance delivery appointments. During these blocks, I insert the MAD, review what the patient should expect regarding fit and feel, and lastly, but crucially important, we discuss home care instructions. After that, we talk about the importance of maintaining a sleep diary.

I always ask my patients to keep track of their sleep schedule and subjective symptoms. This is important because it helps me to determine when the device should be adjusted and when it is time for the follow-up sleep test.

During the dreary days of COVID, I’ve been able to maintain our schedule and continue seeing patients due to an ingenious piece of technology called Doxy.me (Doxy. me, LLC). Despite physical distancing, Doxy. me allows me to virtually see my patients.

Most oral appliances can be adjusted by the patient though clinician guidance. This software is far more personal than phone calls and enables me to stay connected with my patients and be sure they get the care they deserve. Plus, we can see each other’s expressions and smiles.

I also allocate time for patients that have contacted us or been referred to us but have yet to be diagnosed. I connect these patients with SleepTest.com for virtual evaluations and home sleep testing. For a certain percentage of our patient population, this has been a wildly beneficial adjunctive service.

Being a dental sleep hygienist has been such a rewarding transition in my career.

“During the dreary days of COVID, I’ve been able to maintain our schedule and continue seeing patients…”

The physical wear and tear is dramatically less than when I was hunkering over patients all day long scaling and root planing. This path is not without its challenges though.

It can be difficult to remain present and focused with each patient. So much of my role now involves listening and counseling.

That requires full attention and empathy. It can also be heartbreaking to experience so many people suffering with sleep breathing disorders, the difficulty it causes in their lives, and realize how little help there is for them in our current healthcare landscape. I want to do everything I can to help them, but I can’t fix everything. However, I diligently strive to locate resources and cultivate a network of specialists who are wonderful team players and share our singular goal – to give our patients better quality of life through healthy sleep.

All of this culminates in the most rewarding gifts I receive. The gifts of patients coming in to say, “thank you for giving me my life back” or “my wife back.” This means I have helped them, their loved ones, and I played a part in making a real difference in their lives.

So, I wonder sometimes – do I do this for me or is it for them? Does it even matter? Either way, my patients are breathing better, sleeping better, and enjoying healthier lives. That is my blessing. One of my mentors said, “On a good day, we can save a smile, but on a great day, we can save a life.” I want every day to be a great day.

Gina Pepitone-Mattiello is a Registered Dental Hygienist practicing with Long Island Dental Sleep Medicine, the first AADSM accredited dental sleep facility in New York State. In addition to treating patients and educating other hygienists, Gina has published several articles and has lectured internationally on behalf of various educational institutions. Gina also hosts the “Get A Gasp” podcast on The Dental Podcast Network.

DentalSleepPractice.com

53

PRODUCTspotlight

Treating Severe OSA – Versatility is Key

by Steven Olmos, DDS, DABCP, DABCDSM, D.ABDSM, DAIPM, FAAOP, FAACP, FICCMO, FADI, FIAO

S

leep disordered breathing (SDB) is comprised of various structural and neural pathologies of the upper airway. Obstructive sleep apnea (OSA) is among the most prevalent forms of SDB. Regardless of disease severity, OSA has a host of metabolic and cardiovascular comorbid conditions. Mild and moderate apnea is often treated with positive pressure devices including APAP, BiPAP, and CPAP. However, 46% to 83% of patients are nonadherent if compliance is defined as usage for 4 or more hours per night.1 The critical pressure needed to collapse the pharyngeal airway is known as P-Crit. This can be altered by nasal valve compromise or other nasal obstruction. Oral appliances are recognized by the American Academy of Sleep Medicine and as an effective treatment option for OSA. P-Crit can also be affected by the use of oral appliances that give tonus to the muscular airway, essentially stretching the muscle to improve its responsiveness which reduces collapse. This is the basis of how oral appliances function to treat OSA. There are two commonly used techniques for taking a bite relation for the production of oral appliances. The George Gauge Registration (GGR) usually starts from 60% protrusion and then the mandible is titrated for efficacy. This technique can result in temporomandibular dysfunction. The second commonly employed technique, the Sibilant Phoneme Registration (SPR), uses a physiologic three-dimensional mandibular orientation without significant protrusion to give tonus to the airway. A retrospective analysis comparing the results of each technique showed no difference in outcome. The SPR method required fewer calibrations and less jaw movement though.2 The SPR technique was quantified using the pharyngometer which is instrumentation utilizing acoustic reflection to quantify changes in airway from baseline to collapse.3 Using a pharyngometer to measure the volume of the pharyngeal airway and how much it collapses can be a valuable tool to triage whether a patient will have a successful outcome with oral appliance therapy.

As with PAP treatments, there are multiple types of oral appliances.

Devices that can titrate protrusively, vertically, and lift the tongue are optimal for management of this condition. As of this writing there is only one oral device that allows for these changes, and that is the Diamond Digital Sleep Orthotic (DDSO-Diamond Orthotic Laboratory). It is a printed type 12 nylon that is biocompatible and fully adjustable (figure 1). This device is FDA-cleared for the treatment of sleep breathing disorders including OSA.

Improved nasal patency utilizing nasal sprays and nasal dilators can increase the efficacy of oral appliance therapy for OSA according to the Starling Resistor model.

Chronic facial pain and primary headaches (migraine, tension type, cluster) are comorbid with OSA.4 In severe cases of OSA or in situations where there is facial pain and osteoarthritis of the temporomandibular joints in combination with OSA, a hybrid or combined therapy option may be the solution. In severe OSA cases when the patient cannot tolerate exceedingly high PAP pressures, a combination of oral appliance and PAP can be used to reduce PAP pressures to tolerable and comfortable levels.5 Patient complaints about head straps can be resolved via a printed oral appliance that holds a nasal pillow delivery of positive pressure. This appliance is called the Shirazi Hybrid (Diamond Orthotic Laboratory) and can be titrated protrusively and vertically (figure 1). This appliance will decompress the TMJ and limit parafunctional movement so it can be used in patients with TMD and OSA. Innovation and technological developments continue to improve treatment options and versatility.

1.

2.

Steven Olmos, DDS, is an international educator and founder of TMJ & Sleep Therapy Centres International. He is a diplomate of the American Board of Crainofacial Dental Sleep Medicine, the American Board of Dental Sleep Medicine, the American Board of Craniofacial Pain, and the Academy of Integrative Pain Management.

54 DSP | Winter 2020

3.

4.

5.

PC Neuzeret, L Morin. Impact of different nasal masks on CPAP therapy for obstructive sleep apnea: a randomized comparative trial. Clin Respir J 2016. [Epub ahead of print].

Viviano J, Klauer D, Olmos S, Viviano D. Retrospective comparison of the George Gauge registration and the sibilant phoneme registration for constructing OSA oral appliances. Jour Craniomand & Sleep Practice. 2019 Nov 26;1-9.

Singh GD, Olmos SR. Use of a sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath. 2007 Dec;11(4):209-16.

Olmos SR. Comorbidities of chronic facial pain and obstructive sleep apnea. Curr Opin Pulm Med. 2016 Nov;22(6):570-5.

El-Solh AA, Moitheennazima B, Akinnusi ME, Churder PM, Lafornara AM. Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study. Sleep and Breathing 15, 203-208 (2011).

SLEEPhumor

...The Lighter Side of Sleep Apnea

56 DSP | Winter 2020

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