Dental Sleep Practice Winter 2018

Continuing Education

It’s the Air that We Breathe

by Allen J. Moses, DDS; Elizabeth T. Kalliath, DMD; and Gloria Pacini, RDH

The Simple

Sleep Solution Story

by Tarun Agarwal, DDS, PA

WINTER 2018 | dentalsleeppractice.com

PLUS

Oral Appliances:

New Field Study

by Barry N. Chase, DDS, PC, D.ABDSM, D.ACSDD, D.ASBA

Tips to Make DSM Life Easier Supporting Dentists Through PRACTICAL Sleep Apnea Education

by Dr. Carrie Magnuson

PATIENT SCREENING l BITE REGISTRATION l ORAL APPLIANCE SELECTION / FABRICATION

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

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INTRODUCTION

It’s Not the Baton, It’s the Conductor

D

entists like technology – we know we are only one purchase away from the practices of our dreams! The next shiny object will certainly make our lives simpler! Since it will pay for itself so quickly, our wallets may burst! Our patients will be so thrilled with the new instrument that the gushing forth to their friends and family may just cause problems at the front desk with all the new patients flooding the schedule!

Maybe not. Somewhere between the brightly rosy picture that salespeople are wont to paint and the lifeless continuation of the ‘way we’ve always done it’ is the thoughtful addition of today’s exciting innovations to what we use daily to improve every aspect of our business.

Dentists involved with treating sleep related breathing disorders (SRBD) have other considerations – financial, relational, and regulatory – to account for as they choose among the technology available to them.

Amy Morgan, DSP Editorial Board member and the most financially-aware consultant in the business, ‘forbids’ her clients from major purchases unless there is a solid business plan in place to ensure ROI. Not the one the salespeople tend to promote, which often ignores office overhead, but one based on increased service, less overhead, and/or measurable marketing benefit from the new investment. Filter your decisions through a business plan like that and you’ll live with less ‘buyer’s remorse.’

Complicating use of testing technology in your practice is the lack of insurance payment for most devices dentists use. The fact that the same tests are paid if the medical provider orders them produces an annoying layer over the whole deal. There are few policies written that pay dentists for recognized tests, and virtually none for some of the more innovative devices coming on the market.

CBCT, thankfully, has codes in both dental and medical systems.

SRBD almost always involve connection with other providers, most of whom don’t invest their own money in new technology.

They can’t make the decisions we make, so mostly they use and rely on the instruments they have, even if they aren’t state-of-the-art

anymore. It’s difficult to communicate the ‘why’ behind our desire to produce a better image, a different report, or use a testing system that’s not validated with traditional polysomnography. Certainly, there are early adopters in medicine, too, Steve Carstensen, DDS but not as many. Keeping the relationship Diplomate, American Board of going forward often involves bringing Dental Sleep Medicine our medical colleagues along with us as we develop new pathways for identification, communication, and treatment of our mutual patients. Finding benefits for everyone concerned is a key skill as you discuss SRBD management with your professional colleagues. Enthusiasm for how great it is to measure details the other doctor cares little about may result in unproductive discussions.

Dentists are used to few restrictions on how we practice, with little worry about being told ‘no.’ The unsettled debate about who should employ technology capable of detailed measurements means that some dentists are prohibited from using such instruments, for any purpose, for any patients, and other dentists can freely use them for some reasons, but only for some of their patients. Much of the newest technology, such as many wearables, has yet to be categorized or regulated, leaving no one sure whether it’s ‘safe’ for the dentist to use. Everyone has to be careful to ask questions of their regulators as part of their due diligence.

Technology in medicine is a huge boon to people’s health and that’s also true for sleep medicine. As dentists become more important in this field, we’ll be using the newest technology to improve outcomes. It’s fun to use these new devices, and, with the right goals in mind, also can be productive, profitable, and enhance provider-provider relationships.

DentalSleepPractice.com

1

CONTENTS

6

Cover Story

The Simple Sleep Solution Story

by Tarun Agarwal, DDS, PA Using technology to it’s maximum benefit.

14

Field Study

Oral Appliances: New Field Study Examines their Medical Value and Quality-of-Life Impacts

by Barry N. Chase, DDS, PC, D.ABDSM, D.ACSDD, D.ASBA Lessons from real-life practice.

32

20

Continuing Education

It’s the Air that We Breathe

Practical Tips

Tips to Make DSM Life Easier

by Dr. Carrie Magnuson Practical tips learned over many years.

56 2 DSP | Winter 2018

by Allen J. Moses, DDS; Elizabeth T. Kalliath, DMD; and Gloria Pacini, RDH Airway problems begin in the nose.

Expert View

Early Training has Lifetime Benefits

by Judith Dember-Paige RDH, BS, Certified Orofacial Myologist MFT is a growing, vital part of airway therapy.

2 CE CREDITS

With ProSomnus

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–Dr. Erika C. Mason, DDS, D-ABDSM, D-ACSDD

The ProSomnus Continuous Advancement device lets those “muscles kind of stretch slowly and you don’t have to change out any

“

trays. My patients can advance it to their comfort and pace. I like that.

–Dr. Erika C. Mason, DDS, D-ABDSM, D-ACSDD Other leading practicioners agree:

The new ProSomnus [CA] device’s innovative design with A/P “Advancement Markings helps me know exactly where my patient and I are in the titration process, and the precision gives me confidence that each device delivered is consistently accurate to the patient’s anatomy and my prescription.

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CONTENTS

10

Book Review

47

Practice Management

Modern Society, Hidden What Do Gossip and Gum Epidemics: Books to Devour Disease Have in Common?

by Pat Mc Bride, MA, RDA, CCSH DSP’s first book review column.

22

Practice Growth

When You Assume ...

by Chris Bez Not everyone knows what you know.

24

Survey Results

Technology in the Sleep Practice How our readers think of technology.

28

Company Spotlight

Planmeca Group A global leader in health care technology.

38

Laser Focus

Tongue-Ties and Sleep Issues (and More!)

by Richard Baxter, DMD, MS, DABLS We can’t overlook any way to help.

42

Product Spotlight

Why Should You Consider DSM Software?

by Brandie Havell Don’t handicap your practice with old thinking.

44

Technology

Digital Workflow Helps Doctors Respond to Growing Demand for Sleep Appliances Brandon Darcangelo interviews Dr. Stephen Poss Digital tools prepare your practice to be ready.

4 DSP | Winter 2018

by Cynthia Goerig Achieving an office environment based on teamwork.

50

Team Focus

New Technology, Children’s Airway, Same and Similar, OH MY!

by Glennine Varga, AAS, RDA, CTA Every member of the DSM team must be aware.

52

Evolving Practice

Paving the Road to Medical/ Dental Harmony

by Mark T. Murphy, DDS, FAGD, and Edward T. Sall, MD, DDS, MBA It’s coming together, and everyone wins.

54

Digital workflow synergy.

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

VP, Sales & Business Development Mark Finkelstein | mark@medmarkmedia.com National Account Manager Celeste Scarfi-Tellez | celeste@medmarkmedia.com Manager – Client Services/Sales Support Adrienne Good | agood@medmarkmedia.com Creative Director/Production Manager Amanda Culver | amanda@medmarkmedia.com

Legal Ledger

Medicare: Reasonable and Useful Lifetime (RUL) What is THAT?

by Ken Berley, DDS, JD, DABDSM, and Jan Palmer You need to master the information in this article.

64

Publisher | Lisa Moler lmoler@medmarkmedia.com

Technology

Overcoming the 3 most common obstacles in Dental Sleep Medicine with 1 simple solution – technology

58

Winter 2018

Sleep Humor

Front Office Administrator Melissa Minnick | melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.DentalSleepPractice.com Subscription Rates 1 year (4 issues) $129 | 3 years (12 issues) $349 ©MedMark, LLC 2018. 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.

COVERstory

The Simple

Y

ou may have heard that the ‘golden age’ of dentistry has passed us by. With the strengthening economic clout of dental benefit companies, competitive pressures of well-funded ‘corporate’ dental practices, and the financial handcuffs of student and practice debt – it is easy to fall into the trap of believing this thought. I’m here to say that dentistry has never held more promise. Technology has transformed our personal lives for the better and actually gives the solo dental practice more than a fighting chance. Never before have general dentists been able to expand their scope of care than what our profession has witnessed in the past decade. Today, we enjoy the convenience of digital impressions and single visit chairside restorative dentistry, digital 3D radiology and its diagnostic capabilities, digitizing implant dentistry leading to fewer visits and better outcomes, and the virtual planning and execution of orthodontic treatment with clear aligners.

Sleep Solution Story

by Tarun Agarwal, DDS, PA

6 DSP | Winter 2018

COVERstory When I graduated dental school in 1999, I never believed that I would be able to accomplish the scope of care and predictability we are now achieving. Each innovation has allowed me to grow my practice, enjoy dentistry more, and more importantly, has made these procedures more accessible to the dental consumer. To say it boldly, I wouldn’t be doing these procedures without the help of technology.

So, what does all this have to do with Dental Sleep Medicine?

Largely, dental sleep medicine has been forgotten and left behind when it comes to

technological innovations. This has made the practice of obstructive sleep apnea (OSA) therapy more of an ‘art’ than science. Will appliance therapy work? At what position will we achieve the best results? When does one have a follow up sleep study performed? What happens if TMD or bite complications occur? These questions and uncertainties are keeping dental sleep medicine from gaining the national prominence it deserves and patients desperately need! In fact, it’s these concerns that kept me from fully embracing dental sleep medicine in my practice until several years ago.

Luckily for my practice and patients, technology has come around to provide solutions that makes dental sleep medicine more predictable and way more fun!

Technology entering dental sleep medicine is a positive development and will impact oral appliance therapy in the three most important categories – patients, dentists, and team members. For patients, technology will allow dental practices to create awareness by making it easier to have a conversation about OSA and allow patients to better understand their condition through the use of visual aids. For dentists, technology will make appliance therapy more predictable and require fewer visits – making adding OSA therapy less disruptive to the traditional general practice. For team members, technology will make it easier for auxiliaries to better support the doctor and patients in the overall workflow of dental sleep medicine.

A fully digital solution for appliance therapy

Let’s get down to business now. I would like to share with you how today’s technology has transformed how our practice provides therapy for OSA. I’ll begin by sharing our fundamental workflow and then how technology fits into each of these steps.

1. Awareness 2. Diagnosis 3. Treatment

Awareness.

The saying goes that you can’t treat what your patients don’t see. You must help them become aware of their health problems. For most dentists and team members, it has proven difficult to bring up a conversation about sleep apnea.

When we started using CBCT airway segmentation as a non-diagnostic tool to show patients what their airway looked like, and presented the link between medical conditions and sleep apnea, something very interesting happened. Patients actually started asking us questions and leading the conversations.

Dr. Tarun Agarwal represents a new generation of leadership for the dental profession. As a respected speaker, author, and opinion leader, he is changing the way general dentists’ practice. He maintains a full-time general practice in Raleigh, NC that has faced its share of ups and downs. Despite being an ‘in network’ insurance provider, he’s managed to build a successful practice by integrating technology at the highest level.

He produces a weekly podcast called ‘TBone Speaks Dentistry’ and regularly holds seminars and workshops at his 3D Dentists training center. Learn more at www.TBoneSpeaks.com.

DentalSleepPractice.com

7

COVERstory

Segmented airway from SICAT Air

It is my opinion that best practice would be to provide each patient – not just those who we think have sleep apnea – with a 3D colored airway segmentation. The reason being is that it is often the spouse of a patient who has symptoms of sleep apnea. Our goal should be to raise overall awareness of the gravity of OSA.

Diagnosis.

Once you have created awareness and conversation the next step is to encourage the patient to take a test to ‘rule out’ the presence of OSA. This testing can be done using a PSG (polysomnogram) at a sleep lab or at home using an HSAT (Home Sleep Apnea Test).

MATRx device

8 DSP | Winter 2018

MATRx plus device

Responder report

It is important for me to remind readers that the diagnosis of sleep apnea CANNOT be done by a dentist and that I believe it is best practice to have every HSAT scored by a sleep tech and read by a board-certified sleep physician. Circumventing the physician community is not in the best interest of the patient.

While the HSAT is not a new technology, what is different is the ability for a device (MATRx plus, Zephyr Sleep Technologies Calgary, Canada) to be able to assist in the diagnosis and predict whether or not the patient is a candidate for oral appliance therapy. It takes a step further by determining at what protrusive position the patient will achieve maximum results.

The MATRx plus accomplishes this by fitting the patient with a sliding dental tray that is controlled by a micromotor. This motor and attached tray adjust throughout the night in reaction to the measured oxygen response by the associated HSAT device. A patient is designated a responder if their oxygen desaturation index (ODI ) is below 10.

The included Type 3 HSAT enables diagnosis by a physician. Adding the jaw positioning element introduces a new level of technology: Theragnostics. This reflects a combination of diagnosis with immediate determination of potential therapy.

Implementing theragnostics into our sleep apnea workflow has given me, the prescribing physician, and the patient confidence that oral appliance therapy is a good decision. We now know what our optimal end point is and can adjust our starting point to achieve treatment in less time. Because we know what the target position is, we avoid

COVERstory over-protrusion, minimizing disruption to the jaw joint and jaw muscles. Another benefit from this new piece of technology is that it has reduced our chair time and number of patient visits.

Treatment.

So far, we have a patient who has OSA (with proper supporting medical physician diagnosis), the MATRx plus testing has determined that the patient is a responder for oral appliance therapy and at what protrusive position to achieve optimal results.

To fabricate an appliance we need upper and lower impressions and a treatment bite.

Traditionally this has been accomplished via PVS impressions. Today all of this is accomplished digitally. In our office the models are captured using CEREC Omnicam (Dentsply Sirona) and the MATRx plus theragnostic bite is captured via 3D CBCT imaging. 3D CBCT imaging allows the clinician to evaluate the joints and the upper airway (nasal septum, nasal turbinates, and sinuses), any of which can impact overall effectiveness of oral appliances.

Left: Merged Orthophos SL 3D Ai and CEREC data for OPTISLEEP. Right: Deviated bite

So, what is the benefit of fabricating the appliance digitally?

To fully appreciate the benefits of the digital workflow it is best to realize the inherent flaws of the analog workflow as it relates to the impression and bite.

Capturing full arch impressions for appliances is not easy, yet critical. Most of us are using stock trays that don’t always extend far enough distally – leading to an inaccurate capture of the distal tooth. Another common result found on stone models in the lab are pulls on the linguals – which are then ‘guestimate’ corrected at the lab by scraping the model. These points are important because it is the impression that determines the fit of the appliance. Digital impressions allow you to completely and accurately capture all surfaces without distortions.

The bite is also a culprit in the analog method. It is easy for the patient to deviate when capturing the protrusive bite record.

This is often overlooked in the practice while the patient is still present and not noticed until mounted by the laboratory. Appliances made with deviated bites and/or improper mountings can be causes of tooth shifting,

ORTHOPHOS SL

A digital workflow for oral appliance therapy is a positive and gigantic leap forward for the field of dental sleep medicine.

OPTISLEEP appliance

bite changes, and/or TMD issues. Correction at this point means the patient has to be brought back into the practice. Capturing the bite digitally allows immediate visualization and verification. The digital workflow outlined here greatly simplifies the task of proper 3D bite registration.

You can see there are significant benefits to having a fully digital workflow. But we aren’t done yet! There are also benefits to having a digitally fabricated appliance (OPTISLEEP - SICAT). In my experience, there are two main complaints from patients about oral appliances – bulk and bacteria. Both of these are directly related to the analog fabrication method.

Analog sleep appliances are typically made using powder/liquid acrylic. These are inherently weaker and require greater bulk and/or metal reinforcement for strength.

These analog appliances are also more porous and attract more bacteria – leading to early discoloration and a bad odor. Digitally fabricated appliances are slimmer and more comfortable to wear, they are stronger and last longer for the patients, and are healthier due to the significant decrease in bacteria accumulation.

I am hopeful and confident that you can see that a digital workflow for oral appliance therapy is a positive and gigantic leap forward for the field of dental sleep medicine.

It will give more dentists the confidence to step into this growing field and provide quality treatment. Dentistry’s contribution to a population health problem will stand out and more people will seek therapy.

DentalSleepPractice.com

9

BOOKreview

Modern Society, Hidden Epidemics: Books to Devour

by Pat Mc Bride, MA, RDA, CCSH

W

e all look at children’s faces every day in our clinical practices. One kid after another, year after year, they all start to look pretty much the same, don’t they?

And yet, if today’s faces are compared to those of past generations there is no escaping the visual evidence that they are in fact vastly different and in very substantial ways. The migration of the face down and back, the open mouth posture and unbalanced profiles we see now sound the alarm that something is going wrong with children’s craniofacial growth and development.

Jaws: The Story of a Hidden Epidemic

...May change your mind about long-held notions concerning orthodontic practices.

Jaws: The Story of a Hidden Epidemic is must read book for everyone. It belongs in your waiting room, if only to bring awareness and help facilitate sensitive conversations about a child’s growth, development and aesthetic appearance with the families we serve. Tracking the silent epidemic in western civilization which is escalating negative growth and function of the face and jaw, it’s a book about everyone, especially the most precious resource on the planet, our children.

Sandra Kahn, a pioneering orthodontist, and evolutionist Paul Ehrlich track with scientific, clinical, and anecdotal data the decline in development of our jaws revealing the current negative changes in our faces. No, you will not find pages full of citations for refereed literature in this book, but common sense should be your guide when reading. The consequences of decline include jaws that are getting smaller, crowded/crooked teeth which create aesthetic issues in our modern society as well as difficulty in breathing. One interesting notion brought to light has to do with how and why current clinical practices in orthodontics as well as dietary, biological, and cultural changes may be contributing to this negative growth and function trend. The current generation of young people has one thing in common that no other generation 1.

10 DSP | Winter 2018

before them: access to orthodontic therapy.

Once considered a therapy of the wealthy and privileged, today braces are viewed as a customary rite of passage. Dentists and orthodontists have been charged with the Herculean task of identifying and screening for airway and sleep disorders, which makes the information in this book extremely helpful. Jaws: The Story of a Hidden Epidemic may just change your mind about a few long-held notions concerning orthodontic practices. What practitioners either do or do not do to protect and enhance a child’s airway can impact a child’s ability to develop to their full potential.

With grace and poignancy, Kahn and Ehrlich stress that the current rapid negative shift in oral evolution of the face, jaws and health risks posed by possibly obstructed airways must be addressed. To aid parents, teachers, physicians, dentists and clinicians alike, they propose many simple adjustments that can alleviate this growing crisis and introduce alternatives to standard orthodontics that promote proper facial balance, growth, function, correct oral rest posture, and ultimately protect the fragile airway health of all patients. Jaws will change your life. Read it and pass it along to anyone and everyone you care about. You will help save their life too.

Kahn, S., & Ehrlich, P. R. (2018). Jaws: The story of a hidden epidemic.

Jo GN in N3S YD M S leep at le th “W S her ympo ep Ap e 300 e to F sium nea ind S Nov leep P your Sea . 25 - 9 atien First ts ts :0 Reg are Li 0 am ” iste mite r no d w!

Join the Network that Puts You IN-Network DreamSleep and Dedicated Sleep invite you to join the largest group practice for Dental Sleep Medicine, TMJ/TMD and Airway Management in the world The resources you need to cut out the hassle and treat more patients: • IN-Network Medical Health Plan Contracts in all states • Guaranteed rates 2-3X the national average • Patients have the lowest deductible & best price • Seamless telemedicine access to a physician licensed in your state • Physician oversight increases treatment protocol compliance • In-house corporate referrals from national companies • Online, on-demand credentialing • Online Directory listing as a DreamSleep Qualified Doctor • Social media content library • Posters and brochures • One-on-one training for your whole team

Join the Network and Treat More Patients 844.363.7533 n3sleep.com

BOOKreview Sleep Wrecked Kids

As a veteran mother who survived raising one of the worst “sleepers” ever, thirty years later, I eagerly picked up this book and began to devour its contents. Sleep Wrecked Kids has come along right in time to literally save the day with an excellent book on sleep practices for children. There isn’t anyone who hasn’t shuddered at the screaming kid, swinging from the rafters of our waiting-rooms who hasn’t noted that “that kid must have missed his nap!” Working from the staggering statistic that 25%- 40% of all children suffer from some kind of sleep disturbance,

“What is good sleep”?

Not surprisingly, most people don’t know.

2.

Sharon Moore deftly identifies the myriad of problems that physically, socially, psychologically and developmentally negatively impacting children’s sleep. She connects the dots between disparate issues starting from ground up with the simple question, “What is good sleep”? Not surprisingly, most people don’t know, and to be honest, when the kids are all over the map at the end of a long day, whatever works to get them to sleep is what most people do.

Moore’s insight and positive practical solutions to improve sleep are invaluable.

Dentists and orthodontists can easily refer to and adapt her behavior and sleep charts for assessing a child’s sleep during screening and exams. Asking the right questions may just change a life. Her introduction of medical interventions and specialists will help providers locate their own “team” of community referrals to address the children in your practice. The emphasis on children’s airway, oral rest posture, myofunctional therapy, craniofacial development and overall health outcomes could not come at a better time with so many children suffering from sleep and breathing disorders and not enough providers who are trained to help them. Finally, understand that kids who don’t sleep well have parents who don’t sleep well because of them. The ‘taking care of adult’ sleep tips and tools are for everyone. This book belongs on the waiting room table and given to every new mommy-to-be. Give them a great start!

Plan ahead – this book will go missing.

Buy extras. It’s just that good.

Moore, S. (2018). Sleep wrecked kids: Helping parents raise happy, healthy kids, one sleep at a time.

Pat Mc Bride, BA, RDA, CCSH, has spent 38 years as a full time clinician and educator in the fields of dentistry, respiratory medicine and dental sleep medicine. Her extensive experience in clinical, laboratory, research and educational arenas has led to the development of interdisciplinary care model delivery systems used by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. She sits on the Board of Directors for the American Academy of Physiological Medicine and Dentistry in New York. Pat continues to work hands on with patients while lecturing internationally on subjects relating to breathing and sleep medicine, dentistry and precision medicine systems to best benefit all patient populations. Serving the underserved and marginalized patient remains a passion and priority for her. She is a Ph.D. candidate at Fielding Graduate University. She has one grown daughter who shares her passion for social justice and education, serving as a fifth grade teacher in the inner city Oakland, CA.

12 DSP | Winter 2018

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FIELDstudy

Oral Appliances: New Field Study Examines their Medical Value and Quality-of-Life Impacts

by Barry N. Chase, DDS, PC, D.ABDSM, D.ACSDD, D.ASBA

O

n March 1, 2016 a Field Study was initiated on patients of record at Chase Dental Sleep Care (CDSC), a dental sleep medicine practice dedicated to treating sleep breathing disorders located in the New York Metropolitan area.

The Field Study involved the collection of patient data pre and post oral appliance insertion primarily focused on Quality of Life outcomes while forgoing the rigor of research and data analytics necessary for a white paper study intended for publication in a professional journal.

To help assess and quantify the effectiveness of oral appliances1 in treating obstructive sleep apnea (OSA), our dental sleep practice conducted a two-part patient survey.

Exclusively for Dental Sleep Practice readers, we present our findings, which aim to help answer these two important questions about the device’s effectiveness: • What is the appliance’s medical value (MV)?

• What is the appliance’s impact upon patient quality of life (QOL)?

The results, within both dimensions, were generally quite positive. Taken together, the results strongly suggest that oral appliances represent an effective tool for OSA therapy.

About the surveys

A total of 249 patients had been delivered a mandibular advancement device and

14 DSP | Winter 2018

advised to come back for follow-up. Of that overall population, a subtotal of 115 patients came back, while 134 did not. Returnees thus represented less than half (46 percent) of the overall group.

Among returning patients, a total of 23 were included in the MV analysis as they underwent both pre and post oral appliance insertion sleep studies. Their medical progress was measured on the basis of before-andafter scores on the Apnea-Hypopnea Index (AHI) and/or the Respiratory Event Index (REI). For the purposes of this analysis, the two techniques are treated interchangeably.

For the QOL survey, a total of 111 patients were asked to complete a twelvequestion survey.

When reviewing the survey results, it is important to keep three considerations in mind: First, a particular patient’s MV results may not align with that individual’s QOL results.

Patients showing medical improvement may report relatively less QOL improvement. The reverse may also be true.

Second, survey results may be affected by variations in the time periods over which assessments are made. For both MV and QOL results, some outcomes may take longer to manifest than others. If a follow-up test for MV test occurs too soon, or if QOL questions are asked too soon, results could potentially yield false negatives. More benefits may manifest over a longer period.

FIELDstudy Third, more than half of the overall patient pool instructed to return for follow-up chose not to return. Yet all patients can generally be presumed to have a personal and medical interest in the appliance’s success.

While we cannot know for certain, it seems a generally safe assumption that most non-returnees had been content with the appliance’s effectiveness. Along these lines, returnees would presumably tend to be more likely to have product-related concerns.

Satisfied patients would seem less likely to schedule follow-ups. It cannot be ruled out that there might be dissatisfied patients who simply abandoned therapy and chose not to return for follow-up.

So, if we assume that survey respondents would generally tend to be less-satisfied end-users, then the appliance may in fact be more effective than the results suggest. Precise results were not the intention of this field study, but there are helpful findings to assist the clinical team in talking with potential appliance users about the benefits of therapy.

Survey #1: Medical value of the oral appliance

For the MV component of the survey, 23 patients received before-and-after tests.

The MV sample included 13 men ranging in age from 26 to 71 years. The ten women ranged in age from 38 to 76 years. Males represented 56.5 percent of the overall sample.

There was considerable variation in time gaps between the two MV tests. Of the 23 participants, six were re-tested within six months, nine within seven months to one year, and four were re-tested within a period between one year and two years. Finally, six did not get re-tested until two years or more had elapsed.

Patients overall showed a high rate of improvement in their readings. Nineteen patients – amounting to 82.6 percent of everyone tested twice for medical value – came in with better scores.

The results presented in Table 1 suggest that the product may deliver somewhat better results for men than women, with improvement shown for 85 percent of men versus 80 percent of women.

MV survey results also revealed a general trend toward medical improvement with the passage of time (Table 2). What might account for this?

Table 1: Overall “Medical Value” – Survey Results by Gender Patient Category

Patients Showing Improvement in Medical Value

Patients Showing Decline in Medical Value

Male patients (13)

11 (85% of men)

2 (15% of men)

Female patients (10)

8 (80% of women)

2 (20% of women)

Total sample (23 patients)

19 (83% of total)

4 (17% of total)

Sleep scientists understand that the body is adaptive. Inflammation tends to diminish over longer periods. Moreover, as a patient’s breathing improves, we witness both neuroand physiologic-dynamic improvements in the airway, along with other forms of amelioration.

Of 19 participants showing improvement, these three experienced the most substantial improvements: • A 66-year-old woman’s AHI results declined from 39.3 to 1.2 over a ten month span • A 39-year-old man saw his AHI decrease from 41 to 5 over the course of 21 months • A 56-year-old man’s AHI score went from 50.9 to 19.7 over ten months Of four patients exhibiting MV decline, a 65-year-old woman experienced the worst setback. Her AHI score increased from 6 to 11 over a nine-month period.

Extenuating factors could have contributed to downturns experienced by these four patients. Two had gained weight between tests, one had been consuming a larger amount of alcohol, and a fourth had adopted a new sleep position that could have helped lower her score.

Patients report consistent satisfaction with the appliance’s effect on their quality of life.

Barry Chase, DDS is the founder and president of Chase Dental SleepCare, a private practice with 12 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 Am. Ac. 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 Stony Brook Hospital.

DentalSleepPractice.com

15

FIELDstudy Table 2: Medical Value – Patients by Gender and Age, Accompanied by Top-Line Results Males Age

Score 1

Date

Score 2

Date

Time Gap

Score Change

26

5.1 REI

9-2-16

1.5 REI

12-18-16

3 mo

-3.6

39

41 AHI

11-6-14

5 AHI

8-6-16

1 yr 9 mo

-36

40

26.9 AHI

7-31-16

21.9 AHI

5-14-17

9 mo

-5.0

49

12.9 AHI

8-19-13

1.4 AHI

3-17-17

3 yr 7 mo

-11.5

51

11.3 AHI

6-28-16

12.0 AHI

1-17-17

6 mo

+0,7

51

41 AHI

3-19-15

2.2 REI

2-9-17

2 yr 10 mo

-38.8

56

18.2 AHI

5-16-16

10.6 AHI

5-4-17

1 yr

-7.6

56

17.6 AHI

5-26-16

2.6 AHI

12-15-16

6 mo

-15.0

56

50.9 AHI

2-4-16

19.7 AHI

4-4-17

10 mo

-31.2

57

10.1 AHI

3-29-16

6.7 REI

5-13-16

1 mo

-3.4

57

19.7 AHI

5-21-12

1.5 AHI

7-26-12

2 mo

-18.2

67

55 AHI

2-21-14

74 AHI

9-22-16

2 yr 7 mo

+19

71

22.7 AHI

8-27-15

12.7 REI

5-15-17

2 yr 8 mo

-10

Age

Score 1

Date

Score 2

Date

Time Gap

Score Change

38

15.6 AHI

10-2-13

3.1 AHI

9-25-16

2 yr 11 mo

-12.5

43

10.0 AHI

7-1-16

6.0 AHI

1-28-17

7 mo

-4.0

44

8.4 AHI

1-23-13

3.0 AHI

2-6-14

1 yr

-5.4

51

7.0 REI

5-21-16

3.4 REI

12-15-16

7 mo

-3.6

57

23.3 AHI

8-29-11

31.9 AHI

7-22-16

4 yr 11 mo

+8.6

58

9.9 AHI

7-16-16

3.2 AHI

12-12-16

5 mo

-6.7

65

6 AHI

3-1-16

11 AHI

12-2-16

9 mo

+5

66

39.3 AHI

9-9-16

1.2 AHI

7-23-13

10 mo

-38.7

67

20.5 REI

5-24-16

8.8 REI

10-10-17

1 yr 4 mo

-11.7

Females

Survey #2: The appliance’s impact on the patient’s quality of life over time – sleep related

This study’s QOL component consisted of a twelve-question survey administered to 111 patients. Roughly 62 percent of the respondents were male.

Each patient was first asked the twelve questions two weeks after insertion of the appliance, and then again three months after insertion.

Five of the 12 QOL-related questions pertained to the patient’s sleep-related experience. Seven questions addressed the product’s daytime impacts.

Here are summaries of replies to the five sleep-related QOL topics:

Patients are getting more sleep Two weeks after insertion, 54 percent of patients were getting greater than six hours

16 DSP | Winter 2018

of sleep per night. After three months, that percentage had risen to 66 percent.

Patients wake up at night less frequently Two weeks after insertion, 59 percent of patients reported that the amount of times they had woken up at night had decreased.

After three months, that percentage had risen to 69 percent.

Patients experience a more “deep/restful” sleep After two weeks, 65 percent of patients reported a “more deep/restful sleep.” After three months, that percentage had risen to 71 percent.

Patients dream more Two weeks after insertion, 52 percent of patients said they had been dreaming. After three months, that percentage had risen to 57 percent.

Patients snore less After two weeks, 32 percent of patients said they were not snoring on a daily basis.

At the three-month mark, that percentage had risen to 48 percent.

Survey #2: The appliance’s impact on the patient’s quality of life over time – daytime variables The survey also tracked seven daytime variables. Here is a reply summary:

Patients wake up feeling more refreshed After two weeks, 58 percent of patients reported waking up more refreshed. After a three-month period, that percentage had risen to 71 percent.

Patients feel more daytime energy Patients ranked their level of daytime energy on a 1-to-5 scale, from “poorest” to “best.” Two weeks after insertion, 23 percent evaluated their daytime energy at the two highest-tier levels. When asked three months after insertion, that percentage had almost doubled to 45 percent.

Patients feel less daytime fatigue After a two-week period, 55 percent of patients reported feeling less sleepy during the day. When asked three months after insertion, that percentage had risen to 69 percent.

FIELDstudy Patients’ memory improved Twenty-one percent reported that their memory had improved two weeks after insertion. After three months, that percentage increased to 28 percent.

Facial muscles feel increasingly comfortable After two weeks, patients were asked how their facial muscles felt along a five-point, “poorest” to “best” scale. Eighteen percent replied in two poorest levels. After three months, the percentage had declined to 10 percent. The percentage of “best” replies increased from 17 percent to 26 percent.

Clinicians should manage patients’ expectations over how soon to expect results.

Patients feel less discomfort in jaw joints Patients were asked how their jaw joint felt after appliance removal. Responses were listed on a five-point scale, from “poorest” to “best. Two weeks after insertion, 51 percent ranked themselves within the three poorest levels. This response rate declined to 38 percent after three months. The percentage of “best” replies increased from 18 percent to 28 percent.

Patients experienced less tooth discomfort After two months, patients were asked -- on a five-point, “poorest” to “best” scale -- whether the appliance had had made their teeth “sore or sensitive.” Those replying in the two “poorest” categories totaled 21 percent, a figure that declined to 13 percent after three months. The percentage of “best” replies increased from 13 percent to 21 percent.

Positive Results

The QOL survey results show that oral appliance therapy has the capacity to deliver some of the benefits quickly.

In the following questions, a majority of patients had experienced positive results within two weeks: • Waking up at night less frequently (59 percent) • Deeper and more restful sleep (65 percent) 1.

18 DSP | Winter 2018

• Waking up feeling more refreshed (58 percent) • Feeling less sleepy during the day (55 percent)

Conclusions

Here are some top-line conclusions that can be drawn from this two-part survey: Oral appliances appear to hold substantial medical value for patients in treating obstructive sleep apnea and its accompanying symptoms.

Patients report consistent satisfaction with the appliance’s effect on their quality of life.

Some improvements include: • Reduced snoring • Easier to sleep • Waking up at night less frequently Both medical value and quality of life results tend to improve with longer-term product usage.

Oral appliance therapy contributes to QOL improvement, the ultimate goal of therapy for most patients. Clinicians might not consider improved AHI score to be the sole factor determining therapy success.

Here are a few patient management suggestions arising from the survey results: • Since the product’s positive effects seem to improve over time, clinicians should manage patients’ expectations over how soon to expect results • The same suggestion as above could apply to the follow-up sleep study; one possible guideline would be a minimum of three months after the initial sleep study • Encourage patients to schedule follow-up appointments to ensure proper monitoring, re-testing and product usage; and educate patients that the role of follow-up is to titrate their oral appliances for the better therapy results • Educate the patients that AHI increase or no change doesn’t mean the oral appliance therapy fails The survey delivered encouraging results. We urge the dental sleep community to conduct additional research. This will boost our capacity to serve the health interests of our patients – and to minimize the harmful health impacts associated with obstructive sleep apnea.

The appliances were a combination of Dorsal Fin and Herbst design, all manufactured by Whole You Respire Medical, Brooklyn, NY.

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PRACTICALtips

TIPS I

to Make DSM Life Easier

by Dr. Carrie Magnuson

began my dental sleep medicine career approximately 10 years ago. The way I practice dental sleep medicine today is quite a bit different from back then. The old adage of “we learn more from our mistakes than from our successes” rings true. Here are a few tips from lessons I’ve been taught over the years: How do you know where you are if you don’t know where you began?

You must have good pre-treatment records. If a patient comes in with a concern, whether shortly after starting therapy or years later, the first thing I think of is, “Can I compare ‘now’ to ‘then’?” I look for their HPI notes, imaging, pre-treatment measurements, and photos. If my team and I have taken thorough pre-treatment records, then I can assess whether there has been a change. Sometimes a patient says their bite has changed or feels they are no longer biting on a tooth where they were previously occluding. If I can show them where they started, I can address their concern. This goes for interproximal and occlusal contacts, mobility, mandibular posturing, gum levels and even tori. I have used my pre-operative photos to show the patient they had a diastema between 8 and 9 before treatment, so the one they just noticed is not because they are wearing a MAD. One of the well-known potential side effects of OAT is change to the

occlusion. I find it very valuable to use shimstock (Almore International, Portland, OR) to check pretreatment positive contacts.

Don’t just cross your fingers that you have what you need. Take the time at the beginning to have accurate records. Take photos of the teeth in full occlusion and anything that is unusual, such as crowded lower incisors, soft tissue anomalies, canted occlusal planes, and tongue indentations. We send pictures of any midline discrepancies, along with photos of the bite registration, to the lab to verify the 3D bite during appliance fabrication. That way, they also know ‘where we begin.’

Assess!

At your follow-up exams, when you are taking new measurements, are you reviewing the previous information and “assessing” whether there are changes? Or simply documenting the current information? During my annual exams, I display the patient’s previous bite measurements on a screen. While I am taking new measurements I “Assess” whether there are any changes. This is not any different than what the hygienists do when probing. If there are noted changes, I discuss them with the patient to see if it is a problem they want to address. If it is an opening of an interproximal contact, I will talk about possible next steps such as adjusting the inside of the MAD or whether they would like to try Essix retainers. Often times the patient is not even aware of any changes. The same is true for changes in their bite.

AM Aligners/Morning Repositioners: “Mirror, Mirror on the Wall”

Figure 1: Shimstock identifies occlusal contacts

20 DSP | Winter 2018

I have had many patients over the years complain of bite changes. One of the first questions I ask is, “Are you using your morning aligner?”. ‘Yes,” they say. I try the AM aligner in and the grooves of the teeth don’t

PRACTICALtips

Figure 2: AM Aligner in place showing incisal edge fit

Figure 3: TAB therapy allows repositioning of the protruded mandible

fit. “Please tell me how you use it.” They state they put the AM aligner in and squeeze on it and follow the instructions. What I find is they are not checking to see if they are fully seating their teeth into the grooves. I now have models in every exam room with an example of an AM aligner. I show them with the models how 0.5mm away from fully seated “is not good enough”. I instruct them to confirm in the mirror that their maxillary incisal edges are fully seating into the grooves.

They need to use the AM Aligner until their teeth fit into the grooves without effort.

Then, confirm in the mirror. Of course, that also means your AM Aligner, which we make using Thermacryl (Airway Technologies, Carrollton, TX), must allow them to see where their edges fit. Don’t bury the incisal edges of the maxillary incisors in the material, and make sure the shimstock holds firmly on the previously noted occlusal contacts with the AM aligner in place. We picked up this tip from Dr. Jamison Spencer!

TMJs – the lateral pterygoid location. I have them continue for approximately 5 minutes and ask about their bite. I love seeing their eyes light up like I am a miracle worker!

“Wow, my bite feels so much better now!”

Sometimes I will need to send them home with the TAB and have them return once their bite feels better. I have found this is also a helpful tool if the patient is noting muscle discomfort. I tell them to think of it as a getting a “professional stretch at the gym”.

I follow the appropriate follow up exams as recommended by the AADSM at 1 week, 3 months, 6 months, and annual intervals. Often times I will note something even though the patient is completely unaware. It is better if we can help our patients proactively and not reactively.

We try to do the best for our patients – that is what makes us sleep well at night. Being in health care, with variable human responses, we can’t be sure where the therapy will take anyone. But, with excellent records, we can always know where they began.

TAB Therapy I saved one of my favorites for last…I love TAB therapy and so do my patients! We simply cut rectangles out of 3mm bite-guard material to make these TABs. I use TAB therapy when a patient’s mandible is postured forward. If a patient is noting bite changes or I have noted bite changes based on my exam, I will immediately start them with TAB therapy while they are sitting in the chair (after checking for anterior tooth mobility first). I created a short video demonstrating instructions.

The majority of the time, the patient will feel “stretching” of the masseters and around their

If I can show them where they started, I can address their concern.

Dr. Carrie Magnuson is the co-founder of Premier Sleep Associates, a dental practice dedicated to treating obstructive sleep apnea and snoring in Bellevue, Washington. She is a Diplomate of the American Board of Dental Sleep Medicine and a graduate of UOP Dental school. She has taken numerous advanced education courses in Dental Sleep Medicine, including the mini-residency in Dental Sleep Medicine at Tuft’s Dental School in Boston and the Orofacial Pain Continuum at LSU’s Dental School in New Orleans. She lectures on Obstructive Sleep Apnea and Snoring. She has previously lectured nationally on the importance of Oral Cancer Screenings.

DentalSleepPractice.com

21

PRACTICEgrowth

When You Assume ...

by Chris Bez

F

or this issue, I found myself turning over ideas about what to write that would specifically suit the dental sleep medicine market and yet not be something that you’ve read many times before.

I thought about testimonials and how to use them to generate leads and turn patients into practice advocates on your behalf.

I thought about referral resources and how to tell them that you will communicate with them and you will care for their patients as if yours was an extension of their office and the quality of care they want their patients to have.

I thought about insurance and what you can say to the patients to let them know that in your office, their insurance issues are heard and assisted wherever their plans allow, so that you get them the maximum amount of coverage they need to offset the cost of the appliances and their treatment plan.

I thought about languaging and how important what is said from the moment your phone is answered to the moment you walk the patient to the front desk to pay for their appliance is to their experience of your office and their willingness to hit social media sites on your behalf to sing your praises.

I thought about the fact that you truly have multiple markets in the forms of referral sources, existing patients, consumers who have tried and failed at CPAP, and sleep partners of snorers and apnea sufferers who are out there – diagnosed or otherwise.

I found myself trying to couch advice in terms of the economic backdrop you are currently working with. I looked at generational divisions and categories, media in all its forms and delivery systems, preconceived notions that are held by many of the dental sleep medicine doctors I speak to with regularity.

Then I got up to clear my head and happened upon a close associate who is a social media and marketing guru in his own field. We got to talking and I shared the fact that I was having a bit of a challenge landing this one with something that I felt was really worth my reader’s time to consider. In the course of the conversation, he asked me a few questions and then simply looked at me and grinned. You know that look – the one that someone gives

Chris Bez, from a start as a Sales Manager for a national manufacturing company, has became an award-winning Marketing and Advertising Executive, a Professional Executive and Team Coach and a national speaker on marketing and promotions. Today she focuses her attention on niche marketing for dentists – specifically for those practices that have incorporated Dental Sleep Medicine into their patient offering.

She writes and advocates on the imperative of consulting versus selling, and the development of individuals and teams. For more information, contact Chris at cbez@chrisbez.com.

22 DSP | Winter 2018

you when they know what they’re about to say makes infinite sense and it is more obvious than the proverbial nose on your face.

He said simply, “When you get too close to it, you think everyone sees it the same way.” He went on to explain that because of what you know about dental sleep medicine, you assume that others “get it.” He was adamant that non-dental sleep industry people simply don’t understand the real facts about what happens when you don’t sleep vs. what happens when you do. Even more so, that understanding what is at risk isn’t important until you are “in it.” Once you find yourself there, understanding that there is a dental sleep medicine treatment option that is available nowhere else – is one big, fat, important, fact to know. He suggested that unless you’ve been stopped behind someone in the airport going through security, the typical patient has no idea of what a pain it is to get through with your CPAP. That looking like the elephant man while wearing a mask is definitely not for the esthetically conscious and, while he went on for a bit more emphasizing how little people know overall about oral appliance therapy, it basically amounted to this: not everyone understands and knows about OSA and treatment options, and no matter how or where you deliver that message, every once in a while, we all have to get back to basics and tell the real story – the whole story and be really, really clear about it. I thought about what he said – and I have to agree.

SURVEYresults

Technology in the Sleep Practice

H

ow do you use technology to assist your DSM practice? Did you use equipment already in place, or did adding the new service trigger new investment?

Every laboratory producing oral appliances for treating SRBD has a protocol for accepting digital impressions. Some send the files for printing, others print the models themselves, and a few labs are all digital, producing devices with no analog steps. The value of digital recording of physical details is becoming more apparent every year.

I plan to go to digital impressions...

69% DEFINITELY 14% ONLY IF COST 12% ALREADY USE 2% ONLY IF 2% NEVER within 1 year

becomes affordable

manufacturers subsidize the cost

I plan to use compliance monitors...

Upcoming technology, I think...

51%

What we have now is plenty good and we do not need more technology

new technologies are exciting and plan to incorporate them into my practice

62 in the future 20% already use in some devices 13% only if required 3% don’t plan to use %

24 DSP | Winter 2018

20%

29%

Will enable dentists to be more involved in therapy

Is mostly for diagnostics, so dentists won’t be involved

1%

SURVEYresults Analog or digital, I take...

60%

29%

only typical impressions

12%

both typical and digital impressions

only digital impressions

Cone Beam CT, I...

25% send patients to another office to get a CBCT

60%

have a CBCT and have them interpreted by a radiologist

8%

do not use CBCT

have a CBCT in my office and read all or most of the images myself

All mandibular advancement devices put forces on teeth and oral structures. Dentists are the only medical providers capable of judging the appropriateness of this therapy.

Evaluation of teeth, bone support, and associated structures is a key component.

Sophisticated imaging such as CBCT reveals much more body structure than most dentists are trained to interpret. No physician orders an image outside their scope without a radiologist’s oversight.

7%

71%

Regarding imaging, I...

18% use CBCT to evaluate the patient prior to starting OAT

always get a panoramic or cephalometric image prior to beginning OAT

11%

do not need any imaging to feel comfortable starting OAT

DentalSleepPractice.com

25

SURVEYresults For billing service, my office..

52%

Contracts with an outside medical billing service

33% 10% 3%

Provides medical billing in-house Does not bill any medical insurance Software does medical billing for us

I am...

11%

Cash-only, fee-for-service, practice

25%

19%

Submit to commercial insurance only as an out of network provider % Enrolled with one or more Medical insurance plans as a network provider % Out of network with insurance but am enrolled in Medicare as DME provider, either participating or nonparticipating

32

53

Enrolled with a Medical insurance and also Medicare DME

For software, we..

Choices for office systems and billing services involve the entire team. How the office interacts with the patient, other providers, and insurance companies is directly affected by how documentation is created, stored, and accessed. Thankfully, there are many professional services established to help dental teams with creating the right systems for their practices.

30% 32%

use dental software to maintain records for dental and medical services

have a specialized software for sleep related breathing disorders services

38%

keep medical patients only in paper charts separate from dental records

26 DSP | Winter 2018

Learn from top educators

in sleep dentistry at the Greater New York Dental Meeting Sleep Apnea Symposium brought to you by Dental Sleep Practice

K SPEA

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November 25-28, 2018 | Jacob K. Javits Convention Center | New York, NY

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COMPANYspotlight

Planmeca Group

Planmeca showroom in Helsinki, Finland

A global leader in health care technology

S

hiny white design and devices with colors from metallic silver to lime green, 3D-printed skulls of humans and pets in illuminated glass display cabinets, touchscreens surrounding the devices that look like they’re parts of a spaceship.

This futuristic yet inviting pastel-colored scene is not part of a science fiction novel but is reality in a showroom in Helsinki, Finland. This showroom belongs to the Planmeca Group, a company that develops and manufactures cutting-edge Finnish health care technology.

Planmeca Group’s product range covers high-technology dental care equipment, world-class 2D- and 3D-imaging devices, comprehensive CAD/ CAM and software solutions, mammography systems as well as dental instruments, supplies, and services.

President and founder of Planmeca, Heikki Kyöstilä, has seen his company and the industry evolve hand-in-hand. Forty-seven years ago, in 1971, Kyöstilä saw a market opportunity for manufacturing dental equipment after doing business for German companies in the same field and decided to start a company of his own. Today, the parent company of the group, Planmeca Oy, is the third-largest dental equipment manufacturer in the world and also the largest privately owned company in the field.

“It was all about hard work and an urge to put Finland on the map. And today, Planmeca is a global leader in health care technology,” said Kyöstilä.

Planmeca’s aim is to create functional, durable, and beautifully designed products that stand the test of time. Planmeca’s dental care units, X-rays, and software solutions are all designed and manufactured in Finland. Using the latest technology and the best materials, products are tailored to meet

28 DSP | Winter 2018

Heikki Kyöstilä, president and founder of Planmeca

the needs of dental professionals in different markets. Planmeca Group’s advanced mammography and orthopedic imaging products are manufactured by the group’s subsidiary Planmed Oy. Plandent Division of the group is the biggest dental supply and service chain in Northern Europe. The division consists of comprehensive dental supply houses, which offer innovative digital solutions and supply high-tech equipment manufactured by Planmeca. The division also offers a comprehensive selection of high-quality materials and instruments from the world’s leading manufacturers.

Over 98% of products manufactured by Planmeca are exported around the world.

Planmeca Group operates in over 120 countries, employing nearly 2,700 people worldwide.

Kyöstilä explains that a strong commitment to building customer relationships around the world and a passion for innovation guide everything the company does.

Customers provide the company with the focus to consistently develop revolutionary technology and gain a deep understanding

COMPANYspotlight

of the needs of dental and health care professionals. He believes these values have led them to where they are today — at the forefront of the dental industry.

Strong commitment to R&D

The secret behind the success and never-ending innovation decade after decade is, according to Kyöstilä, a strong and unwavering commitment to R&D. “As a privately owned company, we are in control of our own destiny and able to make the long-term R&D commitments that are the driving force behind our innovations.

We also collaborate closely with health care professionals and leading universities. I firmly believe that this dedication to continuous development will enable us to make the work of dental professionals easier and more efficient for many years to come.”

Up to 10% of the company’s annual revenues are invested in R&D. Planmeca’s in-house R&D department employs 140 people: a mixed group of experts, including software, mechanics, and electronics engineers together with usability and industrial designers. Unrivaled scientific knowledge and in-depth understanding of clinical workflows are vital parts of the product development.

be the logical next step, bringing diagnostics and treatment planning into a single workflow. Planmeca’s solution for this was, and still is, the ever-evolving Planmeca Romexis®, an all-in-one software connecting all of the equipment in a dental clinic.

In 2011, Planmeca launched the concept of digital perfection. The company took digital imaging to the next level by enabling the combination of three different 3D datasets (photo, X-ray data, and digital impression) into one complete 3D model.

Planmeca was also among the forerunners to market the integration of CAD/CAM to dental treatment units. Due to the open-source STL file format of Planmeca’s CAD/CAM solutions, it is easy for dentists to connect with the rapidly growing computer-aided dental manufacturing community. The Planmeca FIT™ solution offers dentists a completely integrated and digital workflow with three simple steps — ultra-fast intraoral scanning, sophisticated design, and high-precision chairside milling. All of this is seamlessly integrated into Planmeca Romexis software.

CAD/CAM dentistry is an integral part of Planmeca today — a wide range of open architecture CAD/CAM solutions lets the dental professionals choose their preferred way to treat patients, improve workflow, and opens opportunities in growing the business scope. Planmeca’s newest intraoral scanner, Planmeca Emerald™, was designed on an open architecture platform and lets dentists offer more services by collaborating with laboratories or integrating additional equipment within their office.

Planmeca USA, Inc.

Planmeca USA, the North American Subsidiary of Planmeca, was launched in 1987 and the first to introduce the software-driven dental care unit concept in America. For the past 31 years, Planmeca USA has lead the North American dental industry with advanced dental imaging systems starting with film based, then digital 2D, and now 3D-imaging equipment with patented SCARA (Selectively Compliant Articulated Robotic Arm) technology. Today, it is one of the most admired dental-imaging companies in North America.

Planmeca offers one of the most robust product lines in the world, which includes dental care units, dental lights, dental stools, dental cabinets, intraoral X-rays, intraoral sensors, 2D extra oral imaging, 3D imaging products, chairside milling units, and intra-oral scanners.

“The U.S. is one of the most competitive regions in the dental industry.

As a company, Planmeca USA is poised to solidify its position as a leader

A digital pioneer

Already in the late 1990s, Planmeca realized that a shared software platform would DentalSleepPractice.com

29

COMPANYspotlight

Mill manufacturing line

X-ray production

across several categories within the dental market. A strong product line, energized product launches, and an innovative pipeline will provide the company with upward momentum and exciting times for the U.S. division,” states President for Planmeca USA, Edwin J. McDonough.

Planmeca’s newest technology, Planmeca Viso™, has the capability of capturing the industry’s largest single scan volume covering the entire maxillofacial area. McDonough describes the technology — “the innovation that paves the way for the launch of Planmeca 4D™ Jaw Motion, a new exclusive specialty program, is the only CBCT integrated solution for tracking, recording, visualizing, and analyzing jaw movement in 3D in real-time.”

McDonough describes a company initiative that focuses on offering dentists specialty workflows, more treatment options, and ultimately better patient care through efficiency. “With our current products and additions to the product portfolio, Planmeca can offer solutions to meet the needs of patients needing restorations, orthodontics, and even implants. Anticipating the needs of our clinicians is our number one priority. One area of dentistry that we will be exploring in the future is 3D printing. Planmeca Creo™ C5 is a new product tailored to meet the needs of our orthodontic partners and is primed to be a blockbuster for our CAD/CAM Division,” McDonough says.

All of Planmeca’s imaging, dental care units, and CAD/CAM products are built on open-architecture platforms. Designed with clinicians in mind, Planmeca’s upgradable, modular platform allows doctors to keep up with new technology by easily integrating the newest advances in hardware and software.

Elements of future growth

Planmeca has stayed on the cutting-edge of dental products now for almost half a century. The plan is to stay on the cutting-edge in the future too.

But what does the future of dentistry and health care technology look like?

Kyöstilä sees a digital future ahead.

“We are living in an exciting era. Dentistry is at a crossroads; the digital revolution has already begun. In the future, dentistry will be completely digital, and 3D technology is going to transform the entire field. Software-driven innovations are now the heart of progress, and cloud services are reality. This presents unforeseen opportunities, but also new challenges.”

1971

1979

Planmeca OY founded in Helsinki, Finland

The 1st patient chair brought to market

1975

30 DSP | Winter 2018

2006

1986

The 1st dental unit brought to market

Launched a microprocessor-controlled panoramic X-ray device

Planmeca introduces 1st microprocessor controlled dental chair

1983

This information was provided by Planmeca Group.

2008

Launched all-in-one soft- Planmeca Romexis Clinic ware, Planmeca Romexis Management introduced

Cone Beam Volumetric Dental Unit with symmetrical Tomography system for 3D motorized movements dental imaging introduced enabling fully adaptable unit

2005

“The industry is moving from products to services. In a completely digital dental workflow, it will be of paramount importance that all devices and software work together completely seamlessly. The future will not only be digital, but also increasingly mobile. This reality is at the core of all Planmeca product development,” Kyöstilä explained.

When Kyöstilä describes his visions of the industry’s future, phrases like software, industrial internet, 3D printing, CAD/CAM, 3D, and even 4D keep coming up.

“It is our goal to design and manufacture high-end digital products that work together as smoothly as possible. To achieve this, we have been forerunners in building a rich ecosystem of devices, software, and services. Our unrivaled product portfolio covers everything needed in a high-tech dental clinic: all 2D- and 3D-imaging modalities together with digital treatment centers, CAD/ CAM systems, and software.”

“Software used to be something people received with the device they purchased, but now software is often the most important product. Software is the brains behind the products. We keep developing our software solutions and improving them constantly.

This is all part of our goal to create the most powerful dental ecosystem in the market.”

“At Planmeca, we always operate with the future in mind. The possibilities with CAD/CAM, 3D, and even 4D are endless.

I strongly believe that Planmeca will guide dentistry into the future like no one else can.”

Planmeca USA has distribution in the United States and Canada servicing over 160 dealer locations throughout North America.

Currently, Planmeca USA maintains 42 sales representatives in the field, one of the best management teams in the industry, and 40 technical support professionals with a total of over 135 employees supporting our North American distributors and doctors.

2007

2016

Planmeca Digital Academy launched – education/training

Full range of open CAD/CAM solutions to labs and dentists

2013

2017

Planmeca Emerald Planmeca PlanMill 40 S launched launched

Planmeca Romexis 4.0 – 1st software to combine imaging and CAD/CAM workflow.

Planmeca Viso and 4D Jaw Motion launched

2018

Experience the Planmeca Difference No one understands the demands of the specialist like Planmeca. Colleagues and patients depend on your expert analysis and treatment. Like you, we know the smallest details matter.

Our Planmeca CBCT imaging systems offer advanced technology to support some of the most difficult procedures involving:

•

Dental implants

•

Cleft lip and cleft palate repair

•

Impacted teeth

•

Facial infections and injury

•

Corrective jaw surgery

•

Snoring/sleep apnea

The small things we do help you to deliver the results expected of industry expert.

Learn more about Planmeca 3D imaging systems today.

630-529-2300

www.planmecausa.com

© Planmeca U.S.A. Inc. 11.2018. All Rights Reserved

Planmeca Viso™

CONTINUING education

It’s the

Air

that We Breathe

by Allen J. Moses, DDS; Elizabeth T. Kalliath, DMD; and Gloria Pacini, RDH

Educational aims

The physiology of respiration has a direct effect on every body system.

The airway therapy provided by dentists enables respiration to return to homeostasis, so the providing dentists must be aware of how that system works in the body. The importance of nasal breathing goes far beyond the need to avoid dry mouth.

Expected outcomes

Dental Sleep Practice subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will exhibit the reader will: • Be able to discuss the balance between O2 and CO2 in respiration and how it is affected by breathing changes • Know about how to affect hypocapnia in a positive way • Appreciate that OSA is only part of a group of SRBD that must be accounted for by the provider group for each patient

32 DSP | Winter 2018

Introduction

OSA is a breathing disorder. Breathing is essential to support life. Air must get to and from the lungs for oxygenation and physiological exchange and conditioning of gases. Noses and lungs have a very rich blood supply consisting of venules, arterioles and capillaries. Each one of these is a smooth muscle-controlled group regulated by CO2 levels.

The Physiological Consequences of Mouth Breathing

Breathing supplies oxygen to all 300 trillion body cells, removes excess CO2 and certain waste materials. Earth’s atmosphere contains approximately 21% oxygen. Human bodies require 6.0-6.5% O2. There is more O2 in the atmosphere than the human body requires. Storing O2 in the body is not necessary. Earth’s atmosphere normally contains .03% CO2. 100% saturation of human blood for CO2 is 6.0 - 6.5%. Therefore, more CO2 is required in the body than is present in the normal atmosphere. The body needs to obtain CO2 to sustain life. The body acquires CO2 by breathing. CO2 is stored in the blood and lungs.1 The optimum operating range for human body is between ph 7.35 – 7.45. At pH <6.8 or pH >7.8, cells die. The acid-base balance is regulated by breathing and conversion of CO2 into bicarbonate (HCO3) or carbonic acid (H2CO3). The lungs excrete over 10,000 mEq of carbonic acid per day.

CONTINUING education The kidneys excrete less than 100 mEq per day. Therefore, by altering alveolar ventilation and eliminating CO2, great control over the acid-base balance can be exercised via mouth breathing. A low level of CO2 results in alkalosis. Mouth breathing accelerates the breathing rate. Hyperventilation results in respiratory alkalosis.

The blood becomes alkaline when the pH is elevated above 7.45. The O2 becomes bound to hemoglobin (Hg) and is not released to cells. This is called the Bohr Effect. As CO2 levels in arterial blood drop, the strength of the bond between O2 and Hg increases, reducing the amount of O2 available to cells.

Patients can have a normal blood oxygen level but if the CO2 level is too low, the oxygen is not released to the body’s cells.

It is important to monitor the breathing rate. At 40 mg of mercury pressure (Hg), the diaphragm moves. This occurs at 6.5% CO2 in lungs. Humans are triggered from birth at 40 mg. Below 35 mg Hg pressure is considered hypocapnia. Ideal breath rate is 6 – 10 breaths/minute. Rapid breathing is 14 – 18 breaths/minute. Rapid breathing resulting from mouth breathing and depletes CO2. Hypocapnia, respiratory alkalosis, poor binding of O2, smooth muscle spasm, enuresis, HBP, snoring, hypoxia, reduced energy, and disturbed sleep can result from overbreathing.2 Mouth breathing bypasses the filtration, warming and humidification system of the nose. The mouth can deliver 5 times as much air to the lungs but the air is unconditioned and dry. The bronchiolar reflex shrinks the airway passage to reduce quantity of irritating air. Breathing becomes rapid and shallow. Lung tissue produces mucus to protect itself. CO2 levels become lower (hypocapnia) and blood pH increases. Respiratory alkalosis ensues.

Correct, diaphragmatic breathing behaviors can be taught.3 There are behavioral

Pathophysiological Consequences of Hypocapnia and Respiratory Alkalosis • •

• • • • •

Hypoxia Hemoglobin Changes - Release of oxygen t - Release of nitric oxide t Cerebral Vasoconstriction Coronary Constriction Cerebral Glucose Deficit Buffer Depletion Bronchial Constriction

• • • • • • • • •

Neuronal Irritability GI Tract Constriction Mg / Ca Imbalance Plasma Potassium Deficit Plasma Sodium Deficiency Antioxidant Depletion Platelet Aggregation Muscle Fatigue Muscle Spasm

Symptoms Related to Hypocapnia and Respiratory Alkalosis • • • • • • • • • •

Physical Performance t Phobias Migraine Hypertension ADHD Asthma Attacks Angina Heart Attack Cardiac Arrhythmia Chronic Fatigue

• • • • • • • • • •

Blood Clotting s Panic Attacks Hypoglycemia Epileptic Seizures Sexual Dysfunction Sleep Disturbances Allergy Irritable Bowel Syndrome Repetitive Strain Injury Pain

Psychological Consequences of Hypocapnia and Respiratory Alkalosis • • • • •

Personality Changes Executive Dysfunction Problem Solving Skills t Cognitive Skills t Concentration t

• Memory t • Behavioral Disorders s • Apprehension, Fear, Panic, Frustration s

Dr. Allen Moses has had a dental practice in Sears/ Willis Tower for over 25 years and was assistant professor at Rush University for 15 years in the department of sleep research and clinical practice. He is the inventor of The Moses® intraoral sleep appliance distributed worldwide by Modern Dental Lab, and the Express4Sleep™.

He has four US patents and has written more than 30 articles on sleep dentistry, facial pain and temporomandibular disorders.

DentalSleepPractice.com

33

CONTINUING education training methods and biofeedback methods.

Results can be objectively measured by capnometry, measuring End Tidal CO2. Patients who have had surgery to treat obstructed nasal breathing often habitually mouth breathe afterward. They need to be retrained behaviorally to nasal breathe.

Dentists can treat hypocapnia related to overbreathing in several ways. Oral appliances can be used if their design is based on the premise that the more room they can create for the tongue to fit in the mouth, the less likely it is to collapse on the airway during sleep. Design of the oral appliance should enable the patient to comfortably keep the

lips closed. Excellent oral appliances facilitate placement of the tongue as far forward as possible, even touching the lips. Excellent oral appliances allow placement of the tongue in the roof of the mouth with no interference from palatal acrylic.

There is good evidence that the myofunctional correction of breathing behaviors taught during the day persist at night. Behavioral retraining instruction on OSA patients given during the day for a thirty day period persisted at night when measured by PSG, according to studies by Puhan4 and Guimaraes.5 The success of this type of study will also be discussed in another paper in this series as substantiating OSA as a soft wired problem.

CPAP is interesting. It has the positive effect on hypocapnia of causing the CO2 level to rise because patients are forced to breathe against a positive pressure gradient and CPAP reduces the breath rate. CPAP can also have a negative effect when too much pressure from the nasal pillows causes the mouth to open. Too much pressure from a full face mask has been reported to cause central apneas and acidosis.

Conclusion

Capnometer – uses nasal canula

Screen showing capnometer results Screen for biofeedback training

34 DSP | Winter 2018

Diagnosis of OSA and treatment with CPAP and/or an oral sleep appliance may not put enough pieces of the puzzle in place to give the clinician a comprehensive picture of the patient’s health status. A diagnosis of OSA established solely by PSG, is a “rulein” diagnosis with a narrow clinical focus.

OSA is merely one of several sleep breathing disorders. As such, a diagnosis of OSA does not rule-out other possibilities such as chronic hyperventilation and its attendant co-morbidities such as respiratory alkalosis, hypocapnia, smooth muscle spasm, hypoglycemia, asthma attacks, ADHD, cardiac arrhythmias, chronic heart diseases and type 2 diabetes. It may appear that the patient is merely nonresponsive or noncompliant to sleep apnea treatment. Diagnosis of chronic hyperventilation/hypocapnia is easily accomplished by PSG, history, examination and a capnometer study. Dentists should have familiarity with these modalities to either use them as treatment methodologies or be knowledgeable enough to refer patients to trained health specialists.

CONTINUINGâ&#x20AC;&#x160;education Treatment of hypocapnia/respiratory alkalosis/chronic hyperventilation can often be non-invasive and largely utilize cognitive behavior therapy and psychological re-education. The results of successful treatment of chronic hyperventilation can be very gratifying. Treatment of sleep disordered breathing is dependent on clinicians having a broad education and training in basic sciences as well as OSA, to apply that education to clinical experience. Dentists can play a pivotal role in both treatment and/or referral.

1.

2.

3.

4.

5.

Guyton AC, Hall JE, "Textbook of medical physiology" Chemical Control of Respiration; WB Saunders 1996 ed 9 527-528 Kamel KS, Halperin ML, "Fluid Electrolyte and Acid-Base Physiology: Problem Based Approach"; Elsevier, 5 ed, 2017 Buteyko Breathing Method. Shut your mouth and change your life, McKeown P, TEDx Galway, http://www.youtube.com/ watch?v=mBqGS-vELs0 Puhan M, Suarez, A, et.al. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomized controlled study. BMJ 2006;332 (7536)266-270 Guimares KC, Drager LF, et.al. Effects of oropharyngeal exercises of patients with moderate obstructive sleep apnea syndrome. Am J Crit Care Med 2009 v179 962-966

Screen for biofeedback training

Business Trends in Dental Sleep Medicine April 5-6, 2019

Jonathan Lown, MD

Kent Smith, DDS

Scott Craig

Arthur Feigenbaum, DDS

Jayme Matchinski, JD

Gy Yatros, DDS

Cindy White

Richard Monahan, DDS, MS, JD

Mark Murphy, DDS

John Viviano, DDS

Ellen Crean, DDS, PhD

Randy Curran

Aria Resort and Casino | Las Vegas, NV www.DeltaSleepInternational.com

Business Trends brings you some of the top trainers, consultants and thought leaders in Dental Sleep Medicine. This is your chance to hear directly from the experts that are transforming our industry to help improve your business.

DentalSleepPractice.com

35

CONTINUINGâ&#x20AC;&#x160;education

Continuing Education Test

CE CREDITS

Certificate Details

REF: DSP Winter 2018

__________________________________________________________________________________ FULL NAME __________________________________________________________________________________ AGD REGISTRATION NUMBER

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits.

Subscribe and receive up to 8 CE credits for only $129 by visiting www. dentalsleeppractice.com. To receive credit, complete the 10-question test by circling the correct answer, then either:

__________________________________________________________________________________ LICENSE NUMBER

n Post the completed questionnaire to: Dental Sleep Practice CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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To provide feedback on this article and CE, email us at education@medmarkmedia.com Legal disclaimer: 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.

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It's the Air that We Breathe by Allen J. Moses, DDS; Elizabeth T. Kalliath, DMD; and Gloria Pacini, RDH 1. A PSG study with an AHI of 5 - 15 does not rule out: ________ a. obstructive sleep apnea b. hypocapnia c. respiratory alkalosis d. hypoglycemia e. all of the above

5. The nasal valve contributes which closest percentage of resistance to nasal airflow ______ a. 30% b. 50% c. 70% d. 90%

2. During inhalation the human nose performs __________ a. warming b. filtering and cleaning c. olfaction d. dehumidification e. all of the above

6. Oral appliances used for treatment of OSA _________ a. reduce pharyngeal resistance by dilating the oral airway b. push the tongue to the floor of the mouth c. should shift user from nasal to oral breathing mode d. prevent collapse of the nasal valve

3. Allergy is a histaminic reaction not characterized by ________ a. vasomotor rhinitis b. mucosal hyperemia c. vasoconstriction of nasal mucosa d. obstructed nasal breathing 4. Nasal airflow resistance is decreased by _________ a. erect posture b. exercise c. rebreathing, which lowers blood CO2 d. nasal vasoconstriction

36 DSP | Winter 2018

7. Platyrhine noses __________ a. well developed nasal valve b. more efficient for heat recapture c. higher surface area to volume ratio d. more laminar airflow 8. Which is not a functional adaptation characteristic of mouth breathers: __________ a. soft palate is raised to create palatal seal

b. mandible drops c. tongue is lowered from palatal contact d. tongue shape flattens e. swallow is with teeth together f. all are true g. none are true 9. Anatomic adaptation characteristic of mouth breathers __________ a. long face b. anterior open bite c. high palatal vault d. habitual open mouth e. forward head posture f. all of the above g. none of the above 10. Which of the following four statements is false: ________ a. Kids who suck their thumb are mouth breathers b. Storing O2 in the body is not necessary c. As arterial CO2 drop, the strength of the bond between O2 and hemoglobin increases, reducing O2 available to cells d. Mouth breathing increases breathe rate and reduces blood CO2 levels.

LASERfocus

Tongue-Ties and Sleep Issues (and More!)

by Richard Baxter, DMD, MS, DABLS

A

tongue-tie is a thick, tight, or short string of tissue under the tongue that restricts the tongue’s movement and causes a functional issue. Collectively, tongue-ties and lip-ties are referred to as tethered oral tissues. They are often misdiagnosed or misunderstood, and they are quite common. The frequency with which anterior tongue-ties occur is estimated to range from 4-10% in the general population, and posterior tongue-ties have been reported in as many as 32.5% of infants in a recent study.1 For a tight piece of tissue to qualify as a tongue-tie, it must have a functional impact on nursing, speech, feeding, or sleep. Infant problems arising from tongue-ties include painful and prolonged nursing episodes, poor stimulation of maternal milk production, reflux, slow weight gain, gassiness, and a host of other issues for mom and/or baby. As babies advance to eating solids, tongueties can lead to gagging, refusing food, spitting out food, and picky eating. Speech delays, articulation issues (trouble with R, L, S, SH, TH, and Z sounds in particular), and stuttering may arise as well. Finally, sleep is often impacted, beginning in infancy.

If tongue-ties remain untreated, they can lead to structural and functional changes in the craniofacial-respiratory complex and can impact sleep throughout the lifespan.

Tongue-ties and low tongue resting postures often lead to or exacerbate mouth breathing. Mouth breathing prevents the brain from experiencing the deepest level of sleep. As a result, people who mouth breathe at night often awaken unrefreshed. Children and adults may be getting the right quantity of sleep at night, but many are not getting the quality of sleep that they need.

Snoring is a red flag and signals that obstructive sleep apnea or sleep-disordered breathing is likely. Upper airway resistance and poor nasal breathing can be caused by a smaller-than-normal nasal cavity, deviated septum, or high arched palate.2 All of those may develop when there is insufficient pressure from the tongue against the palate both in utero and during infancy.2 A baby with an anterior (near or at the tip) tongue-tie or a hidden (submucosal) posterior tongue-tie is often born with a high arched palate. These common tethers keep the tongue in a low position in utero, so the palate does not receive its natural resting pressure from the tongue, and instead of a broad, flat

38 DSP | Winter 2018

palate, the baby is born with a high arched or “bubble” palate which leaves less room for the base of the nose and less volume available for the nasal cavity. Tongue-ties also lead to several of the main causes of breastfeeding cessation, including nipple pain, trouble latching, and concerns that the baby is not getting enough milk.3 It has been demonstrated in many controlled studies that releasing tongue-ties, whether classic near-the-tip anterior tongue-ties or posterior tongue-ties, improves breastfeeding outcomes, allows mothers to nurse more comfortably, and helps babies to suck more efficiently.4–8 It is said that nursing is nature’s palatal expander—meaning that the action of breastfeeding works to broaden the palate and increase the size of the nasal cavity.

Many airway issues that continue into childhood and even adulthood can be traced back to factors in infancy which promote the high palate; for example, low tongue posture (often from a tie), bottle-feeding, and a defective swallow. A tongue-tie release in infancy along with breastfeeding can help prevent adult airway constrictions by allowing the infant to develop a broad, flat palate and spacious nasal passages and sinuses.

As the baby matures, after 6 months of breastfeeding, the practice of “baby-led weaning,” or simply introducing solid food as early as safely possible, encourages the

LASERfocus baby to chew different textures and helps to develop the jaws better than pureed baby food. Mothers should still breastfeed until the baby is at least 12 months old, or longer, as mother and baby desire. More exercise of the jaws beginning at birth and throughout growth and development means an increased size of the jaws and decreased risk of malocclusion, less need for orthodontics, and even avoiding wisdom tooth extraction.9 Conversely, if a person’s jaws are less developed, the tongue is forced to rest down and reside in part of the throat, taking up valuable airway space. If the palate is narrow and the lower jaw is restricted or retruded, the lower jaw also takes up airway space. This phenomenon can also occur from a tongue that is held down by a tie. The tongue is then unable to rest in the palate, so functionally (even if the palate is broad) the only place left for the tongue to go is backward, which closes off part of the airway. Narrow palates and soft palate elongations have been associated with tongue-ties in a recent study.10 After full tongue-tie releases, children and adults are often found to sleep more deeply, snore less, exhibit fewer movements, and feel more refreshed in the morning. Often the parents and patients themselves report better concentration and less hyperactivity as well. It is fascinating that a hidden string can have such a dramatic impact on human physiology and quality of life.

Often after a frenectomy or tongue-tie release procedure, the patient will notice a deeper quality of sleep and the parents will notice less snoring, less movement, less waking, and better mood in their child.

These findings are some of the most consistent findings in our pediatric patients and often result within the first few days after

Figure 1: An infant with a lip-tie and to the tip anterior tongue-tie, before and immediately after laser release.

Figure 2: Example of a typical posterior tongue-tie release in a child. After CO2 laser release, minimal to no bleeding, and clean margins with precise control of the surgical site.

the procedure. Older children and adults will require therapy (myofunctional, speech, bodywork, etc.) for a full resolution of symptoms, and many with narrow dental arches will need expansion and growth appliances to make room for the newly released tongue. For some young children, a release has the potential to improve the quality and quantity of sleep, which impacts not just the child, but the entire family.

Case Report

A nine-year-old autistic male patient who had trouble with speech, feeding, sleep, and reflux was presented by his mother for evaluation. His symptoms included frustration with communication, speech delay until age 5, poor speech intelligibility, chronic reflux since infancy, poor weight lifelong (4th percentile), and anterior loss of milk during bottle-feeding as a baby. Solid feeding had always been a challenge, and he was a “very slow eater.” He packed food

Dr. Richard Baxter is a board-certified pediatric dentist and a diplomate of the American Board of Laser Surgery.

He lives in Birmingham, AL with his wife Tara, and twin girls, Hannah and Noelle. He is the founder and owner of Shelby Pediatric Dentistry and Alabama Tongue-Tie Center where he uses the CO2 laser to release oral restrictions that are causing nursing, speaking, dental, sleep and feeding issues. He is also the lead author and publisher of the new book Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More. He had a tongue-tie himself, and his twin girls were treated for tongue and lip-tie at birth, so for him, this field is a personal one. In his free time, he enjoys spending time with his family, reading, and outdoor activities. Dr. Baxter also participates in many overseas dental mission trips and is an elder in his church, The Church at Brook Hills.

DentalSleepPractice.com

39

LASERfocus in his cheeks “like a chipmunk”, choked and gagged on food, and spit food out frequently. His sleep quality and quantity were both poor according to his family. He had difficulty going to sleep, awakened easily and often, slept in strange positions, moved and kicked at night, ground his teeth, breathed orally at night, and snored often.

His tongue-tie was a posterior tongue-tie and was therefore not recognized by his healthcare providers. It was not deemed to be a likely contributor to any of his issues previously (which is common in children with autism).

It is fascinating that a hidden string can have such a dramatic impact on human physiology and quality of life.

After a full history was obtained and all related symptoms, risks, and benefits of the procedure were discussed with his parents, they chose to have him undergo a lingual frenectomy. The instrument utilized was the 10,600 nm CO2 laser (LS-1005 LightScalpel, Bothell WA). The area was anesthetized with a compounded topical anesthetic, but neither nitrous oxide, oral sedation, general anesthesia, nor injected local anesthetic were used. A mouth prop was used, as well as two assistants to stabilize the patient, who was initially combative, but with the CO2 laser, the procedure was quick, and he calmed down even during the procedure itself. After 10 seconds of lasing at 3 W pulsed (Non-SuperPulse), 29 Hz, 72.5% duty (2.1 W avg), the tissue was vaporized with no bleeding or stitches, and minimal discomfort to the patient. The patient was instructed to perform oral exercises at home for three weeks postoperatively and the parents were shown how to do wound lifts if he would allow them. Two weeks later, the patient returned for a visit, and the mother reported that his “sleeping and eating improvement [had] been unreal.” It was easier for him to communicate, he was less frus-

40 DSP | Winter 2018

Figure 3: Before release, tight thin string noted underneath the tongue lifting up mucosa on the alveolar crest (left). Immediately after CO2 laser release, mucosa and fascia are removed, leaving genioglossus untouched with minimal to no bleeding, and no sutures [patient movement led to the blurry image] (center). Two weeks postoperatively, healing progressing well, less tension noted (right).

trated when eating, his appetite had improved, he was swallowing more easily, he was finishing more of his meals, he was spitting food out less often, he was not gagging or choking on food at all, and he had less reflux. His sleep was also significantly improved. He fell asleep more easily and awakened less than before the frenectomy. He moved and contorted his body less during the night. He snored less, stopped mouth breathing and quit grinding his teeth.

Children experiencing sleep issues should be evaluated for speech, feeding, and other disorders, and if these are present, they should lead the provider to suspect a tongue-tie. An examination by a tie-savvy provider should be performed. Releasing a tongue-tie can and does impact sleep quantity and quality in addition to nursing, speech, feeding, and growth. The CO2 laser release is quick, very low-risk, and minimally invasive. It should be the first-line treatment for children and adults who present with symptomatic tongue-ties, in conjunction with an interdisciplinary team including myofunctional therapists, speech therapists, ENTs, and for infants, lactation specialists.

More information on tongue-ties can be found in the recently released book, Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More by Dr. Richard Baxter, DMD, MS, and seven other healthcare professionals. Available on Amazon.com.

1.

Martinelli R, Marchesan I, Berretin-Felix G. Posterior lingual frenulum in infants: occurrence and maneuver for visual inspection. Revista CEFAC 2018; Available from: http://www.scielo.br/pdf/rcefac/v20n4/1982-0216-rcefac-20-04-478.pdf 2. Huang YS, Quo S, Berkowski JA, Guilleminault C. Short lingual frenulum and obstructive sleep apnea in children.

Int J Pediatr Res [Internet] 2015;1(003). Available from: http://orofacialintegrity.com/wp-content/uploads/2015/05/ short-ling-frenum-and-sleep-apnea.pdf 3. Odom EC, Li R, Scanlon KS, Perrine CG, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatrics 2013;131(3):e726–32.

4. Berry J, Griffiths M, Westcott C. A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeed Med 2012;7(3):189–93.

5. Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics 2011;128(2):280–8.

6. Ghaheri BA, Cole M, Fausel SC, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope 2017;127(5):1217–23.

7. Ghaheri BA, Cole M, Mace JC. Revision Lingual Frenotomy Improves Patient-Reported Breastfeeding Outcomes: A Prospective Cohort Study. J Hum Lact 2018;890334418775624.

8. O’Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otorhinolaryngol 2013;77(5):827–32.

9. Kahn S, Ehrlich PR. Jaws: The Story of a Hidden Epidemic. 1 edition. Stanford University Press; 2018.

10. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional - morphological study. Orthod Craniofac Res 2017;20(4):237–44.

PRODUCTspotlight

Why Should You Consider DSM Software?

by Brandie Havell

M

ost proficient and prolific dental sleep medicine (DSM) practices utilize a dedicated DSM software. Why is this and what criteria should you evaluate when considering adoption of a DSM software?

Based on a combination of formal surveys and informal feedback from nearly 100 dentists, it can be summarized that the appeal lies in the added efficiency, separation of dental and medical charts, as well as medico-legal and payer compliance.

Steve Green, DDS, of Fishers, IN stated that “my DSM software ensures that records are accurate, correspondence with physicians is generated and digitally faxed, and exams are just much easier than using my practice management software. Plus, it’s important to keep my DSM records separate from my restorative records.”

Gy Yatros, DMD, co-founder of the DS3 software agrees. “We are experiencing an increasing number of dentists that aim to transition from restorative dentistry to only treating DSM patients. A dedicated DSM software empowers dentists to get a valuation of their restorative practice while separating DSM production. When they sell, their DSM practice travels with them in their DS3 software.”

Another important consideration involves medical insurance. Oral Appliance Therapy is typically a covered medical benefit. When billing medical insurance, there is exposure to the possibility of a payer audit. Most practices are uncertain about this process and the right DSM software can help safeguard them in the event they are audited. Some DSM software products allow practices to mitigate risk and eliminate the need to share restorative patient information with auditors.

One should also consider ease of use and how robust the platform is.

Several survey respondents noted their software was difficult to navigate which ultimately resulted in under-utilization. Others noted that they

switched from one DSM software to another because they needed a tool with expanded functionality such as connecting with their biller, ordering home sleep tests, transmitting lab cases, and connecting with their practice management software.

Lastly, but ranking high among survey respondents was the importance of training and continual support. Many surveyed stated that they purchased antiquated software and received minimal training. This left many feeling buyer’s remorse about their decision while others exclaimed that their choice’s ongoing support has been worth the cost of their subscription.

There are several DSM software tools available and numerous considerations when shopping. Contact the companies, ask your peers, seek testimonials, and request a demo to ensure that you make the right choice for your practice.

Brandie Havell is a Dental Sleep Medicine jill of all trades who has served as the lead Member Support Expert at Dental Sleep Solutions, LLC for over 11 years. She has trained and supported thousands of dental practices to help implement OAT during that time.

DS3 Software Physician Letter Feature

42 DSP | Winter 2018

TECHNOLOGY

Digital Workflow Helps Doctors Respond to Growing Demand for Sleep Appliances

B

randon Darcangelo, Carestream Dental’s CS Solutions and Educational Institutes sales director, recently sat down with Dr. Stephen Poss to discuss the growing demand for sleep devices, the tools to make a sleep practice successful and where the specialty will go in 2019.

We’ve seen a huge jump in the spread of sleep dentistry and the demand for sleep appliances. Why do you think that is?

Awareness around obstructive sleep apnea (OSA) has grown as medicine and dentistry have taken a more integrated look at our health. Doctors from across many specialties such as cardiology and pulmonology, are recognizing the significant ways that sleep, or lack thereof, can influence the quality of our lives. The word has gotten out to patients. They are learning about the risks of going untreated – hypertension, stroke, atrial fibrillation, just to name a few. They might not know what kind of therapy might be best for them, but they do know a friend or relative who’s receiving treatment or they found something during a Google search. Patients are coming to dentists by their own volition and requesting specific treatment for sleep apnea.

Intraoral camera image representing crowded oropharynx and inadequate tongue space

Carestream Dental CS 3600

44 DSP | Winter 2018

Also, though it varies by case, some patients are looking to sleep appliances as an alternative to CPAP machines, which can be cumbersome, claustrophobic and can even cause colds and flus if not properly cared for.

Of course, the CPAP is the standard choice, but patients often much prefer a discrete sleep device to treat their mild to moderate OSA. For example, I had a 20-year-old male patient present at my practice. He didn’t want to lug a CPAP machine to college with him. The CS 9300 CBCT system (Carestream Dental) was used to acquire a 3D volume and the CS Airway module was then used to visualize restrictions in the airway. Having a color-coded visual tool for case presentation helped the patient understand why one course of treatment was better than another.

In his case, the restriction was purely genetic; however, a sleep device could improve his sleep apnea between 70-80 percent. He was able to make an informed decision about the success of treatment and was perfectly happy to use a sleep device rather than a CPAP machine while at school.

With this growing demand, what are some of the tools you’ve found useful to run a successful sleep practice?

Like most of the trends in dentistry these days, the answer is digital. I’m sure practicing sleep dentistry and creating sleep devices could be done with traditional impressions, but what has really streamlined things in my practice is the use of an intraoral scanner.

There’s obviously less mess without having to deal with PVS materials and trays and it’s also more accurate1 for ensuring the device fits correctly and functions properly. I use a CS 3600 (Carestream Dental) to acquire 3D impression models; it’s part of an open system so I can choose which lab I work with.

There’s a growing number of labs specializing in mandibular advancement devices, which has also contributed to the spread of sleep dentistry. I use several oral appliances like ProSomnus and Panthera. I can upload the scanned files while the patient is still in the office, which makes for a quick turnaround from the scan to the appliance.

I also rely on my CBCT system for 3D scans and a full field of view of the airway and TMJ, as the more images I can provide for insurance purposes the better. The colorful 3D images also aid in case acceptance and patient education. Of course, having the CBCT scans and 3D digital models help with documentation when it comes to liability, which is just as important to sleep dentistry as it is to orthodontics. For example, I recently had a patient bring in a nearly new, clearly unused sleep device. He claimed the device had worn down his teeth, but I was easily able to pull up the documentation from his first appointments and point out that that’s simply how they were to begin with.

Obviously, patients are seeing huge benefits from sleep dentistry regarding their overall health and quality of living, but what are some of the benefits you’ve seen as a doctor?

Over the past 10 to 15 years, I’ve worked

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TECHNOLOGY stead, I can send the patient’s digital impression to the GP or the GP’s lab and indicate that they make the shape, height and contours of the crown to the exact specifications of the natural tooth that was scanned when the sleep device was fabricated. The GP and the lab has all the information they need, and the patient is assured their device will still fit.

We’ve already discussed the growth in sleep dentistry, but where do you see it going from here in 2019?

Example of color-coded visualization of the airway with automatic measurements provided by CS Airway module

to expand the sleep side of my practice so I can provide patients in my region with the best overall care. Sleep dentistry truly changes people’s lives and it’s gratifying to see how relieved and happy people become with quality sleep.

I’ve also noticed that it’s easier to work with referrals thanks to my digital workflow. Patients usually come to me for one thing – their sleep device – and once they have it they go back to their general practitioner. However, down the line if they crack a tooth and need a crown, it’s important that the restoration follows the exact contours of the device or it won’t fit. This can cause a lot of stress for a patient (and the restorative dentist.) Not only is the patient dealing with getting a new crown, but they’re terrified the device that has changed their life might not fit anymore. The dentist has to adjust an unfamiliar device without confidence that it will fit well enough again.

Insurance only covers one sleep device every three to five years so if the new crown is slightly off the patient has to pay for a new one out-of-pocket. In-

A graduate from the University of Tennessee College of Dentistry, Stephen D. Poss, DDS, lectures internationally on esthetic dentistry, sleep apnea and TMD. He is a Diplomate with the ABCDSM, ACSDD in dental sleep medicine and a Fellow with the American Academy of Craniofacial Pain. Dr. Poss is an active consultant to several dental manufacturers for new product development and refinement.

He has had numerous articles published in most of the leading dental journals. Dr. Poss maintains a restorative and TMD practice in Brentwood, Tennessee. He can be reached at drposs@satmj.com.

Brandon Darcangelo has 17 years of experience in the healthcare industry and oversees the sales, development, and the strategic launch plan for Carestream Dental’s CS Solutions portfolio, the company’s CAD/CAM product line.

46 DSP | Winter 2018

I believe sleep dentistry today is what implants were 10 years ago. The growth we’re seeing is amazing, and, much like implants, it’s being fueled by technology and advanced education. First, new software will be a gamechanger for doctors practicing sleep dentistry. For example, the latest version of the CS 3600’s acquisition software includes Multiple Bite Capture. This allows doctors to capture up to three different bite registrations, which are necessary for the labs to design and manufacture sleep devices. The registrations are captured in one scan and the bite matrix files can be exported as one file and sent with the dataset to the lab and viewed in its CAD software. Additionally, we’ll see more continuing education and advanced training opportunities to support doctors interested in sleep dentistry. This education will ensure doctors are providing their patients with the best care as they expand the services they can offer.

Further growth of sleep dentistry will be powered by increasing patient demand. Just within the past few years, we’ve seen numerous articles about sleep apnea and its dangers in patient-facing publications, such as the New York Times and Forbes. As previously mentioned, this means patients will be specifically seeking doctors and coming to appointments more informed about OSA than in the past. Our profession needs to be prepared to handle the tidal wave of patients so we can provide the life-changing treatment they need.

1.

Nedelcu R, Olsson P, Nyström I, Thor A. Finish line distinctness and accuracy in 7 intraoral scanners versus conventional impression: an in vitro descriptive comparison. BMC Oral Health.

2018 Feb 23;18(1):27.

PRACTICEmanagement

What Do Gossip and Gum Disease Have in Common?

by Cynthia Goerig

D

entists want to look forward to going to the office. And although they wish they could just perform dentistry and not have to deal with all of the business aspects of running a practice, they realize that a typical day may include glitches that need their attention before the first patient arrives.

When team member drama is involved, there may be tension and hushed whispers, and the doctor may be visited by multiple team members who update him with the latest gossip, suggesting who is to blame and who did something wrong. Many times the practice owner knows he/she needs to address the situation but doesnâ&#x20AC;&#x2122;t, hoping it will go away. Throughout the day, similar distractions pop up, as well as scheduling and patient issues, and by the end of the day, the dentist could feel drained and exhausted, privately wishing he/she could just do dentistry and feel the satisfaction of completing cases.

What do gum disease and gossip have in common? It is an infection that can spread without being noticed, and when left to fester, puts the patient or practice at risk and is expensive to treat.

Gossip is a very expensive production killer. The negative energy is off-putting to the rest of the staff and the patients, and creates unnecessary frustration and stress for the doctor. Gossip damages relationships, manipulates emotions, creates competition, causes drama in the workplace, and affects the bottom line. In one case, an endodontic office was burdened with gossip and a team openly at war with each other. When this was addressed, production increased 36%, slightly better than the doctorâ&#x20AC;&#x2122;s prediction.

Gossip fosters an environment of blaming

A little-known fact: people who gossip are terrified of conflict.

When there is a culture of blaming, people do not take responsibility to solve problems. They would rather make someone else DentalSleepPractice.com

47

PRACTICEmanagement wrong for fear they will get in trouble. People will look to find fault in why something doesn’t work and manipulate your time in convincing you who is to blame.

Now imagine …

Step One Answer the following questions: 1. What is your vision for how people treat each other in the office?

2. What is your vision for how the team will treat patients?

3. Pick three to five words to describe the daily environment or culture of the office. (examples — focused, supportive, fun, friendly, professional, caring, etc.)

Step Two Call a team meeting, and schedule it for 30 minutes.

Step Three At the meeting ...

1. Share your answers from questions 1-3. Explain why this is important to you, coming from an authentic and vulnerable place, and ask for their help in achieving it. People respond when they feel they are needed to help create the new vision.

2. Create a “no gossip” rule. Explain why there is no gossip, and how it will reinforce the culture you want.

3. In closing the meeting, ask if everyone can get behind this and agree by raising his/her hand. When people physically act, like raising their hand, in front of everyone, they feel like they have a choice and are more likely to follow through.

Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving. A culture of celebration is pronounced around the success of the day and a team that rallied to close the office and prepare for the next day.

Imagine not having to remind your team members what they are supposed to do that they already knew, and that it was taken care of. They know the objectives and goals, and are invested in the vision — not only sharing it, but also owning it.

Envision that the team felt safe at work, knowing that if something goes wrong, the whole team will help.That they don’t criticize or judge each other; instead, they look for the strengths in each other and improve upon their weaknesses.

Finally, imagine when leaving the office, the team thanks the doctor and each other, leaving everyone energized, proud of the team and the work they do. In short time, the practice becomes known as one of the best to work for.

The good news is that you are a few steps away from this possibility. (See the steps in the red box.)

The most effective way for a change in a practice to occur is for the leader to model it. I recommend printing out your three to five words that describe the environment you want to cultivate (from question 3) and review them daily.

Inspire your team to make the change, model it, and become the office that everyone wants to work for.

Cynthia Goerig, Master Teacher and Executive Coach, has been developing leaders and coaching dental executives for more than 15 years. She is the founder of Legacy Life Consulting and CEO of Endo Mastery. Legacy Life Consulting, Home of Inner Legacy Seminars, was created to bridge the gap between clinical mastery and leadership excellence for dental specialists. Personal Leadership is taught in seminars, executive coaching, and team programs. Legacy’s unique method is taught in small groups where doctors uncover patterns that prevent them from effectively leading their practice. For a consultation or program availability, please contact David Stamation, Chief Operating Officer, at 208-946-3894 or email: david@legacylifeconsulting.com

48 DSP | Winter 2018

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TEAMfocus

New Technology, Children’s Airway, Same and Similar, OH MY!

by Glennine Varga, AAS, RDA, CTA New Technology s we approach the end of 2018 three factors are clear: 1. New technology is here to stay! 2. Pediatric airway awareness has risen and 3. Same and similar is a new way of life for those of you filing Medicare claims.

Ok great! You may be thinking so what does this have to do with the way our practice integrates dental sleep medicine?

These three factors may not impact you at all right now, but that’s sure to change. When looking at these three factors from a team approach, can you identify the common denominator? Let me give you a hint… insurance. Let’s take a look at these three areas and the impact they may have within your practice. Please understand there may be insurance benefits available for the three factors if certain circumstances are fulfilled. Many people and institutions are pushing for benefit allowance.

A

so, no problem. But wait – some insurance plans deny benefit for the oral appliance after MATRx plus theragnostics. This is where I’d like to know the benefit I’d be forfeiting to obtain a diagnosis. It could be $200 or $2000. Because my insurance may dictate how my diagnosis was obtained and because new technology is moving so quickly, insurance companies may not recognize new methods. In addition, some plans require a physician to order the method of diagnosis as a result of a face-to-face and the physician may not recognize these new methods.

Time will catch up to technology. For now, keep your patients informed of new technology and what options are available. Keep in mind that if the patients feel the value of the service, the allowable benefit from insurance companies may not matter to your patients.

Personally, I understand the thoroughness of obtaining a diagnosis, outcome predictability and optimal starting position in one night, so the value outweighs the cost for me.

Whether you have this new technology or another home sleep apnea test device, this scenario will occur with patients and it’s in your best interest to find a way to navigate this conversation.

Children’s Airway

Wearables, smart blankets, and radio frequency technology are around the corner!

How about the technology of Dr. John Remmers’ MATRx plus™ (Zephyr Sleep Technologies Inc. Calgary, Canada)? This option could be ideal for patients to not only obtain an airway diagnosis but also predict effectiveness with an oral device. OH MY! If I’m a patient presented with this option, I’d go for it! Not only will I know if an oral appliance will work for me, I will also have a starting position that will allow for most optimal results. Sign me up! Depending on my insurance, there may be no benefit for this option.

Do I care? I can pay the fee for this service,

50 DSP | Winter 2018

The American Dental Association (ADA) has a policy statement regarding every dental office screening for sleep disordered breathing in both children and adults. The ADA is currently working on guidelines of what this evaluation will be. Talking about children’s airway with families is practice-building and solutions to help guided growth and tongue posture are patient friendly and very successful.

Since form follows function, it makes sense to look at why a child is functioning the way he or she does. Why are the dental arches forming in a certain shape or the occlusion of the teeth aligning a certain way?

Ask questions of the guardians of your little

TEAMfocus patients. Change your medical history to ask questions about observed snoring, mouth breathing or bed-wetting. During the inaugural Children’s Airway Practical Conference at the ADA’s headquarters in Chicago, IL in August 2018, Dr. Christian Guilleminault described how airway can be influenced as early as conception and during the time in the womb. There were dentists present at this conference whom have dedicated their entire practices to performing frenectomies on infants presenting with tethered oral tissues, such as tongue-tie, which prevents proper development of the maxilla, the base of nasal airway. Providing the service of early orthopedic or orthotropic therapy can be a new revenue stream for your practice while helping children in your community breathe and sleep to their fullest potential. Most dentists I’ve met over the years become involved in children’s airway because of a child of their own and, once they understand the impact this therapy makes, it becomes a passion driven by many success stories and thank you cards. The ADA is hosting their next Early Breathing Conference March 3-4, 2019, also at the ADA’s headquarters in Chicago, IL. The August event sold out.

Same and Similar

Dr. Ken Berley and Jan Palmer write about this in detail elsewhere in this issue. Federal regulations at 42 CFR 414.210(f), the Reasonable Useful Lifetime (RUL) of DME, state that the RUL of any piece of DME is to be not less than five (5) years. What does this mean for your practice?

If you’re not a Medicare DME supplier, you will continue to do what you normally should be doing: Having your Medicare beneficiary (patient) sign a Medicare private contract letting them know there is benefit with Medicare DME, but they cannot get that benefit because you are not a DME supplier. Your Medicare beneficiary (patient) has to agree to pay you knowing there is a Medicare benefit.

If you’re a Medicare DME supplier and your patient has had PAP therapy within 5 years, there will be no allowable benefit for your appliance. In this case your Medicare beneficiary (patient) should be presented with an Advanced Beneficiary Notice (ABN). This is a form your Medicare beneficiary will read and decide which option is best for them. Based on the options selected,

a claim may or may not be submitted. The ABN is only to be used in the event you do not expect Medicare to allow benefit. If PAP therapy has not been attempted within the past 5 years and all the criteria of Medicare Local Coverage Determination (LCD) have been met, the ABN should not be used because you expect payment. CMS is allowing dentists to appeal by providing documentation showing that CPAP usage has been discontinued by the treating physician, that all Medicare regulations were followed to the letter, and all payments for PAP therapy have ceased. Then, and only then, Medicare will consider an appeal for MAD benefit. This isn’t a new regulation, but Medicare’s internal systems needed to catch up to the rule in place for several years. Now that their system is communicating properly it is in our best interest to inform the patient when benefit is not allowed due to the Same and Similar rule. Everyone on the team needs to master the communication skills necessary around this complex and confusing topic.

Embrace what the future has in store for us. Use new technology to educate your patients and empower their decisions. Take a look at children’s airway therapies or whom you may be able to refer to and work with in your community. Stay on top of the latest information coming out of Medicare – it sets the stage for private insurance companies to model.

Tell your patients about the new technology and help them feel the benefit to them.

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

Glennine Varga is a team, business development and sleep coach for Arrowhead Dental Laboratory. She has been a TMD and dental sleep medicine trainer and speaker with an emphasis on medical billing and documentation for over 15 years. She is a member of the Academy of Dental Management Consultants (ADMC) and a professional member of the National Speakers Association (NSA). Glennine was an expanded duties dental assistant, certified in TMD with the American Academy of Craniofacial Pain. She is a visiting faculty at University of Tennessee’s DSM mini-residency, The Pankey Institute and Spear Education’s dental sleep medicine courses. Glennine currently teaches Total Team training and co-teaches Airway Management and Dentistry for the Dr. Dick Barnes Group seminars.

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EVOLVINGpractice

Paving the Road to Medical/Dental Harmony

by Mark T. Murphy, DDS, FAGD, and Edward T. Sall, MD, DDS, MBA

A

recent survey of board certified sleep physicians shed some light on ‘WHY’ physicians are concerned with Oral Appliance Therapy. Although they are concerned with comfort/compliance, insurance coverage and side effects, it is efficacy that took center stage. While turning a blind eye to their own comfort/compliance issues and side effects is not productive, standing tall on efficacy can seem strange considering CPAP’s record. At ProSomnus, precision engineered and manufacturing solutions are helping pave the road to a better understanding and acceptance of OAT from physicians and recent studies. Cistulli1 noted that health outcomes were similar after one month of OAT and CPAP treatment in patients with even moderate to severe OSA. The conclusion was that efficacy, although near 100% for CPAP, was tempered by compliance and vice versa with regards to OAT. Effectiveness and Mean Disease Alleviation are the true goal.

Addressing Concerns: Efficacy and Compliance

“Medicine is beginning to engage dentistry in this symbiotic health care solution. As is often the case, there is more than one way to approach disease solutions. Driving physician acceptance is a focus that ProSomnus has embraced. Helping more dentists treat more patients with better outcomes…regardless of the treatment modality and working harmoniously, should guide all stakeholders in this arena.”

Edward T. Sall, MD, DDS, MBA Medical Director for ProSomnus® Sleep Technologies

52 DSP | Winter 2018

Efficacy alone without compliance might feel like an unfair criticism, but the graph below shows how much it has improved over the last 20 years. From less than 50% to almost 70% combined with what we know and observe in terms of adherence/compliance should serve to soften the hesitancy of sleep physicians to prescribe OAT. 40% CPAP Compliance reports are common and 4 hours per night for 70% of the nights has been used as the definition for some time.

Recent studies in OAT show nearly 90% compliance 7 hours per night, 7 nights per week. The EFFECTS study2 demonstrated a higher Mean Disease Alleviation for OAT at 56% than that of 50% noted in literature values for CPAP.3 Moreover, the 2015 joint AASM and AADSM guidelines4 state, “Meta-analyses performed using the limited available evidence indicates that OA’s can significantly reduce the apnea hypopnea index/respiratory disturbance index/respiratory event index (AHI/RDI/REI) across all levels of OSA severity in adult patients. There was no sta-

EVOLVINGpractice tistically significant difference in the mean reduction in AHI before and after treatment using OA’s versus CPAP across all levels of OSA severity.” Meanwhile, during the last 20 years, CPAP performance has not improved.5

Addressing Concerns: Insurance and Side Effects All major medical insurance carriers have accepted E0486 and cover it for mild and moderate OSA and many extend coverage to severe cases when CPAP has failed or been refused. Side effects, historically common, are much less frequent as designs and protocol mitigate their experience and frequency.

• Morning Occlusal Guides Designed to Reduce the Chance of Posterior Open Bite.

• Precision Fitted OA’s do not allow for the tooth movement seen in more flexible materials.

• Design Engineered Bilateral Symmetry and Smaller devices help mitigate jaw pain.

• Denser Milled Materials reduce bioburden and hygiene issues.

1.

2.

3.

4.

5.

“ProSomnus has raised the bar in manufacturing and design engineering for OA’s. No longer do we have to accept the variance of the artisanal handmade approach to device fabrication. CAD/CAM and materials that are control cured medical grade are stronger and denser than traditional acrylics or printed nylon appliances.”

Mark T. Murphy, DDS, FAGD Lead Faculty for ProSomnus Sleep Technologies

Cistulli, Peter A., AJRCCM, Vol. 187, No. 8 | Apr 15, 2013. Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea; A Randomized Controlled Trial.

Stern, J.; Lee, K.; Kuhns, D. Efficacy and Effectiveness of the ProSomnus® [IA] Sleep Device For the treatment of Obstructive Sleep Apnea – The EFFECTS Study Poster session 2018 AADSM Baltimore.

Sutherland K.; Phillips CL; Cistulli, P. A. Efficacy versus effectiveness in the treatment of obstructive sleep apnea; CPAP and oral appliances. Journal of Dental Sleep Medicine 2015; 2(4):175-181.

Ramar, K; Dort, LC; Katz, SG; Lettieri, CJ; Harrod, CG; Thomas, SM; Chervin, RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827.

Rotenberg et al. Journal of Otolaryngology-Head and Neck Surgery (2016) 45:43 Trends in CPAP adherence over twenty years of data collection: a flattened curve.

Mark T. Murphy, DDS, FAGD, is Lead Faculty for Clinical Education at ProSomnus Sleep Technologies, serves on the Guest Faculty at the University of Detroit Mercy, is a Regular Presenter on Business Development, Practice Management and Leadership at the Pankey Institute and is the Principal of Funktional Consulting. He has served on the Boards of Directors of the Pankey Institute, National Association of Dental Laboratories, the Identalloy Council, the Foundation for Dental Laboratory Technology, St. Vincent DePaul’s Dental Center and the Dental Advisor.

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

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TECHNOLOGY

Overcoming the 3 most common obstacles in Dental Sleep Medicine with 1 simple solution – technology

W

hy, with all the excitement and evidence, are so few dentists integrating Dental Sleep Medicine? Here are three reasons we have found.

TRIOS Patient Monitoring

1- I don’t have the time to implement Dental Sleep Medicine

Screening. When time is such a limiting factor in practices, efficiency in screening and implementation is key. The “who’s at risk” stereotypes surrounding sleep apnea have long been discarded. The only way to determine who should be tested for sleep therapy is to ask the right questions. Adding the ‘screen every patient protocol’ with imagn™ Sleep Software has proven to be one of the most efficient ways to incorporate sleep into your everyday workflow. With the convenience of both a stand-alone cloud software and a Dentrix Connected module, imagn can work within any practice.

Scanning. Taking records for oral appliances takes time. Using digital technology makes your team more efficient with impressions, creates a faster turnaround time from labs, improves accuracy of fit and comfort of the appliances, and requires less expensive chair time adjusting them. This is a key component to efficiency in treatment. Every laboratory equipped to accept digital data is ready for the industry-standard files that the TRIOS can be set up to produce.

Leading prosthodontist Dr. Jonathan L. Ferencz believes that intraoral scanners like the 3Shape TRIOS will no longer be used just on specific cases but rather become a part of a practitioner’s daily routine. He says, “Basically, I see professionals using 3Shape TRIOS on not just any patient, but every patient.”

2- I fear changing the bite, patient dissatisfaction, and liability 3Shape TRIOS® MOVE

54 DSP | Winter 2018

The saying ‘airway trumps bite’ is true, but still a bit unsettling. To help protect yourself,

3Shape will soon release a new application: TRIOS Patient Monitoring. It documents and tracks bite and dentition changes. This, added with the convenience of having digital data and records for life, make intraoral scanners a key component of Dental Sleep Medicine. In addition, with 3Shape TRIOS intraoral scanner you get documented full-arch accuracy and an easy 3D bite registration. The result is consistently well-fitting appliances. The experience for the patient – no goop – and the wow factor of the technology also serve to create an ideal patient experience.

There are basic practice guidelines you must know. When consents are needed, how to store and track them, and how to work with the medical field. imagn Solutions, together with 3Shape, have put together an education program to teach just that - the practical approach to Dental Sleep Medicine. Understanding the protocols and processes is essential for efficient implementation and decreased liability.

3- I don’t know how to bill medical

As one of the most underutilized tools in dentistry, medical billing is seen as a negative, not the opportunity it truly is. imagn Solutions has a team entirely dedicated to helping practices succeed with medical billing. Sleep procedures, including the appliance, CBCT, office visits and even testing are some of the simplest procedures to submit claims for. Starting with education and supported by software, imagn is what many are acclaiming to be the most advanced, yet simple, software they have used. Truly a game changer for many practices.

Whether you want to do the billing yourself or outsource to imagn Billing, there is a solution for every practice.

Learn the digital workflow of imagn Solutions and 3Shape in their ‘Practical Approach to DSM’ and ‘Medical Billing’ courses throughout the country in 2019.

Choose 3Shape TRIOS to ease your Dental Sleep workflow

Go digital with the 3Shape TRIOS intraoral scanner for a consistent, easy and fast workflow for oral sleep appliance therapy Documented 3Shape TRIOS full-arch accuracy* scanning and automatic bite registration improve appliance fit and efficiency Cloud-send 3Shape TRIOS digital impression directly to 6 integrated leading oral sleep appliance manufacturers and hundreds of labs

For more information: 3Shape.com/DentalSleep Please ask your reseller for availability of 3Shape products in your country/region

Dental Sleep Medicine courses offered by imagn Solutions and 3Shape For the full 2019 schedule: imagnsolutions.com

• Medical Billing for all services • Increase case acceptance • Get paid for what you do

• Screen every patient • Digital Workflow • Discounted Medical Billing

* Mullah et al., 2017, Accuracy of full‑arch scans using intraoral and extraoral scanners: an in vitro study using a new method of evaluation

Get your patients into dental sleep treatment faster and more comfortably with the award‑winning 3Shape TRIOS ® intraoral scanner

EXPERT view

Early Training has Lifetime Benefits

by Judith Dember-Paige RDH, BS, Certified Orofacial Myologist

O

rofacial Myofunctional Therapy has been around for more than 100 years. It has recently begun to gain prominence in the dental and medical communities as another way of addressing mild to moderate sleep apnea and TMD muscle disorders.

Parents must encourage their children to keep their mouths closed at rest Photos courtesy of Judith DemberPaige

56 DSP | Winter 2018

Orofacial Myofunctional Therapy (OMT) is a series of exercises targeting the muscles of the face, lips, tongue and pharyngeal airway. These exercises neurologically strengthen and reeducate the muscles allowing for better chewing, breathing, and swallowing function.

Every therapy program, whether for a child or adult, is tailored to meet the needs of the individual based on the impact poor muscle function or posture is having on their physiology or observable symptoms. Recognizing and diagnosing an orofacial myofunctional disorder (OMD) in your practice is something a trained dental professional, dentist or hygienist, can do. We used to believe habits such as mouth breathing, snoring, tongue thrust, and tooth grinding were of little importance, but research is showing they may be signs of a serious health problem.

Although it’s best to prevent poor oral habits, early recognition helps keep existing problems from getting worse. Eliminating and retraining poor functioning oral habits is often a difficult task. It’s worth the effort, however, because it improves quality of life every day forward.

Swallowing is a reflex that begins in utero; we take it for granted, thinking that no one needs to be trained to swallow. Before bot-

tles were invented, if a baby could not breast feed, it would die. Functional swallowing and breathing are primitive functions that are learned as an infant though the mechanics of breastfeeding. Breast feeding is hard work for a baby! This effort strengthens and tones the orofacial muscle complex like nothing else.

Strength is required to draw the milk from the breast to get nourishment. Restrictions such as tongue/lip tie, poor feeding posture, or nasal airflow limitations can make it difficult for a baby to be able to feed adequately. Sometimes the work is so exhausting the baby falls asleep while feeding – this is not normal, or cute!

These days not every baby is able to be breast fed, but if at all possible, it is the best way to learn how to swallow and breathe properly for life. Breast feeding teaches the facial muscles function and synchronicity for swallowing and breathing that assists in the formation of a well-formed mature airway. The rhythmic motion of suck, swallow, breathe, teaches the tongue that the palate is home for the tongue. The tongue powerfully flattens the nipple against the hard palate and then moves away, creating a vacuum to draw milk. This action helps lead to the formation of a flat palate. Since the palate is the floor of the nasal cavity, a flat palate increases

EXPERT view

Close an anterior open bite in 10 months with Orofacial Myofunctional Therapy

the size of the nasal area, making breathing space more open and less congested, leading to fewer allergies and asthmatic conditions.

As a child grows, it is important that their tongue sits on the palate at rest; not on the floor of the mouth and not on the teeth. Their lips should be together. As the swallow continues to mature, the presence of the tongue on the palate advances the growth of the mid-face while also continuing to flatten and broaden the palate, creating arch length for the future erupting teeth and healthy nasal airways.

Sleep related breathing disorders are no longer recognized as strictly an adult disease – they can be seen in children as early as infancy. Developing early chewing in babies as young as 6 months – lips together, proper function of the tongue during swallowing and nasal breathing – is key to developing a well-structured face and airway. Myofunctional therapy is the one profession that can help recognize and train those good habits. It is one of the leading therapies that may protect you and your child against sleep apnea.

Growing children who learned to swallow from a bottle generally have a weaker swallow when compared to a child who was breast fed. The bottle, as well as pacifiers and sippy cups, neurologically trains the tongue to remain low. Consequently, their facial structure may not be as well developed. Myofunctional therapy encourages good facial growth promoted by good habits. If poor habits have resulted in craniofacial dystrophy (poor structure related to growth), orthodontic expanders along with the myofunctional therapy is a great way to open the palate for better breathing and improved tongue resting posture. Other improvements often seen include head posture and speech.

As an orofacial myofunctional therapist, my mission in working with children is to make sure they are chewing and swallow-

ing properly, breathing through their nose with lips closed and their tongue is lightly suctioned up into the palate. Addressing their dysfunction with a therapy program while they are young may benefit them for a lifetime.

My goal for adults is different; they are already fully formed. It is just as important for an adult to chew, breathe and swallow properly because muscles functioning out of sync can cause pain and dysfunction. It may also benefit persons with mild to moderate sleep apnea to tone the oropharyngeal muscles, (pharynx walls, soft palate and tongue) with a myofunctional therapy program helping to create an airway that is more open. If an adult (or child) is diagnosed with tethered oral tissues and those are released, myofunctional therapy before and after surgery is critical for success.

Get to know the myofunctional therapists in your community. Once you begin partnering with them on your treatment plans, you’ll be amazed how much better your patient outcomes will be.

Low tongue resting, tongue thrust and active lisping while speaking

Poor swallowing, swallowing with facial muscles, makes early wrinkles

Judith Dember-Paige has practiced dental hygiene for 35 years. In 2009, she received her certificate to practice Orofacial Myofunctional Therapy, and went on to become Certified in 2015 with the IAOM (International Association of Orofacial Myology). She has her own practice in Briarcliff Manor, Westchester, NY and sees children and adult private patients with orofacial myofunctional disorders. Currently, she is retired from dental hygiene, but keeps her license current. Judith practices myofunctional therapy with a team approach. She also lectures to dental groups and parental groups about orofacial myofunctional therapy. In 2005-2008, she created a Children’s Dental Health Curriculum, Smile Wide Look Inside, that includes a text book with a teachers guide; also available in Spanish.

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LEGALledger

MEDICARE: Reasonable and Useful Lifetime (RUL) What is THAT?

by Ken Berley, DDS, JD, DABDSM, and Jan Palmer

I

n writing this article, I have partnered with my dear friend, Jan Palmer. Hopefully, together we can shed some light on the complex subject of Medicare “same or similar” regulations, which have recently resulted in the routine denial of Medicare OAT claims. Federal regulations on the Reasonable and Useful Lifetime (RUL) of a piece of Durable Medical Equipment is a complex matter and readers are, hereby, forewarned that this is the most complicated article that I have attempted on the subject of Medicare Billing. I hope to help each of you understand the details, so you can provide necessary treatment to a deserving population. Don’t give up! I cannot thank Jan enough for keeping me straight and for her tireless efforts to advance the field of Dental Sleep Medicine and Medical Billing.

History of Medicare Durable Medical Equipment (DME) for Oral Appliance Therapy

Dental Sleep Medicine (DSM) took a giant leap forward in 2011, when the Centers for Medicare and Medicaid Services (CMS) opened the door for dentists to participate in Medicare by offering Oral Appliance Therapy (OAT) for the treatment of Obstructive Sleep Apnea (OSA). At the urging of the American Academy of Sleep Medicine (AASM), OAT was classified

58 DSP | Winter 2018

as DME, which is a subcategory of Medicare Part B. As a result, when dentists provide OAT for Medicare patients they are functioning as a medical equipment supplier. While we do not issue canes or wheelchairs, dentists providing OAT are not view by Medicare as a healthcare provider. The decision to place OAT within DME ensured that Sleep Physicians would maintain oversight of OAT and remain in control of patient care. This is due to the fact that all DME requires a physician’s prescription before the equipment can be dispensed. Therefore, no dentist can legally fabricate an oral appliance for the treatment of OSA without a prescription from a supervising prescribing physician.

As a consolation prize for dentists, Medicare did included verbiage which limited the fabrication of an oral appliance (OA) to a licensed dentist. Therefore, any physicians that are fabricating oral appliances for Medicare patients are in direct violation of the currents CMS regulations.

Therefore, for a beneficiary to qualify for OAT benefits, a sleep physician must diagnose the patient’s OSA and the supervising physician must write a prescription for OAT which must then be filled (provided) by a licensed dentist. The diagnosing sleep physician’s notes must reflect the OSA diagnosis. Dentists get

LEGALledger their authority to treat an OSA patients from the diagnosing and prescribing physicians and must rely on the notes of these practitioners to document the appropriateness and medical necessity of OAT for reimbursement.

Regulations Outlined

The local coverage determination (LCD) L33611 and related policy article A52512 outlines what is necessary for OAT to be a covered service. Some of the more commonly misunderstood criteria are: a. The beneficiary must have a face-to-face examination with a physician prior to the diagnostic PSG/HSAT. A copy of this summary should be readily available should Medicare request the notes from the dentist. b. The detailed written order must be issued (signed and dated) by the prescribing physician for the MAD within 6-months from the date of the pre-diagnostic face to face examination. c. The diagnosis of any SDB must be made by a sleep physician and any diagnostic testing for SDB must be ordered by a physician. The LCD specifies a dentist may not order the diagnostic test. d. It is acceptable if the physician that ordered the diagnostic test is not the physician that signs the detailed written order (DWO) for OAT. An example of this would be: Beneficiary sees primary care physician, discussed sleep related issues, PCP orders a PSG/HSAT which is interpreted by

a board-certified sleep MD. The beneficiary may see the PCP or other physician qualified to treat SDB after an OSA diagnosis who then determines the appropriate therapy for the treatment of the patient’s OSA. It should be noted that a post diagnosis appointment with a physician is not mandatory under the LCD. The OA must be provided by a licensed dentist. As a medical supplier, this makes it possible for dental offices to enroll as DME suppliers. Physicians cannot legally provide OAT and bill Medicare. OAT is a covered Medicare benefit if appropriate for the patient and medically necessary.

Once an OSA diagnosis is made by a physician, the treating dentist is provided a signed DWO (prescription) for OAT. The supplier/dentist is then required to provide a Medicare approved appliance that has been fabricated by a Medicare approved lab. The information on which labs and appliances are Medicare approved can be found on the Pricing, Data Analysis and Coding (PDAC) website www.dmepdac.com.

Readers should refer to Local Coverage Determination (LCD) L33611 and the related oral appliance policy articles (A52512 and A55426) for documentation requirements for OAT for treatment of OSA. A thorough understanding of the LCD and related articles is mandatory for any dentist filing Medicare. Therefore, keep these articles available as a reference!

Reasonable and Useful Lifetime for DME

Federal regulations at 42 CFR 414.210(f), the Reasonable Useful Lifetime (RUL) of DME, state that the RUL of any piece of DME is to be not less than five (5) years. Under the RUL, Medicare will not benefit multiple pieces of DME that are utilized to treat the same condition. For example, Medicare would likely refuse benefits for a motorized battery powered wheelchair and a standard wheel chair. The same or similar provision is an attempt to prevent the payment of duplicate therapy (i.e. you only get one wheelchair). Therefore, if Medicare has paid for a piece of DME for the treatment of OSA, any new claim that you submit within 5 years for the treatment of OSA will be denied. A beneficiary cannot have two pieces of DME that have been determined to be the “Same or Similar” to treat OSA. Sadly, CMS has determined that CPAP and OAT are “similar” pieces of DME use to treat OSA.

Dr. Ken Berley has practiced dentistry in Arkansas for over 35 years and practiced law for over 22 years and is licensed in Arkansas and Texas. He is a Diplomate of the American Board of Dental Sleep Medicine and a Fellow of the American College of Legal Medicine. For the past 10 years, he has focused on the practice of sleep disordered breathing and has developed many of the forms and consents routinely used in sleep medicine. Dr. Berley and his wife Patty, own Berley Consulting, providing mentoring, training and forms for those practitioners wishing to take their DSM practice to the next level.

Jan Palmer, FAADOM – Educating on proper medical documentation and the break-down of policies for Medicare and private insurances has been her passion since 2000. In addition to national speaking and consulting roles, Jan works with the Provider Outreach and Education committee for Medicare DME for Jurisdictions A and D, has co-authored an e-book on Medicare, sits on the board of directors of the WNY Dental Managers Group, is a Fellow of the American Academy of Dental Office Managers, a facilitator with the American Academy of Dental Sleep Medicine (AADSM) Mastery Course, a member of the Academy Dental Managers Consultants (ADMC), Dental Consultants Connection (DCC), Dental Codeology Mastermind Committee and the Dental Experts Network while maintaining a management position with a practice exclusive to treating sleep apnea, putting theory into practice every day.

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LEGALledger Medicare will pay for the replacement of a piece of DME during the first five years of use if the item is lost (due to extenuating circumstances such as flood, hurricane and natural disasters), irreparably damaged or the beneficiary’s medical condition changes such that the current equipment no longer meets the beneficiary’s needs. Replacement due to irreparable wear during the period of reasonable useful lifetime is not covered.

Since CPAP and OAT have been classified by CMS as same or similar devices, under the RUL guidelines, Medicare will only pay for one of these therapies every 5 years for the treatment of OSA.

March 2018: Medicare Same or Similar Denials

For the last seven years, dentists have been filing Medicare for OAT without any significant problems. Then in March 2018, CMS updated their system in response to the increased payments for OAT. The “Same or Similar” system update was in response to some patients utilizing both CPAP and OAT, which violates CMS regulations. Medicare’s system is now fully updated and programed to automatically deny any claim for OAT if Medicare has paid for CPAP within the last 5 years. The enforcement of the CMS “same and similar/ RUL” policy has significantly affected many DSM practices. Since the March update, the OAT Code is linked to the CPAP Code as same or similar devices for the treatment of OSA. Therefore, as of March 2018, if a Medicare beneficiary has had a CPAP for more than 90 days within the last 5 years, any claim submitted for OAT will be denied.

A MAD delivered prior to the certification of PAP will be paid with no denial.

Why is 90 days the magic number? During the initial 90 days of PAP rental, the treating physician is expected to evaluate whether CPAP is the best therapy to treat the beneficiaries OSA. Once satisfied with compliance and efficacy of CPAP therapy, the treating physician signs a Medicare CPAP Certification. Certification is appropriate whenever the beneficiary utilized CPAP for 4 hours or more per night for a minimum of 21 out of any 30-day period within the first 90 days of CPAP usage. If a Medicare patient has had a CPAP for more than 90 days, you can be sure that Medicare has funded the PAP therapy. Once the certification is signed and Medicare pays for the PAP therapy, any oral appliance submitted will deny due to RUL.

CMS position on Same or Similar for OAT

Repeated letters to the Medical Directors at CMS have finally resulted in some concessions. It is now the position of CMS that if a dental practitioner can provide documentation showing that CPAP usage has been discontinued by the treating physician, that all Medicare regulations were followed to the letter, and all payments for PAP therapy have ceased, then, and only then, Medicare may benefit OAT.

Documentation Needed for Appeals?

What if the patient fails PAP after 91 days of use?

If the beneficiary “fails” PAP therapy after day 91, the probability of overturning a denial significantly decreases. The claim will be denied due to the RUL regulations. Treatment timeline must be well documented,

60 DSP | Winter 2018

and the ordering physician must now enter an order to “discontinue (DC) PAP therapy” and order OAT. If the ordering physician’s notes do not show that CPAP was discontinued, Medicare will not benefit OAT. As a side note, these requirements are problematic from a legal standpoint, as no reasonable Sleep Medicine Professional should DC any therapy without an alternative therapy in place. In other words, if PAP has been prescribed by a physician, it might be a breach of the standard of care to DC this therapy before a MAD has been delivered. Additionally, the beneficiary’s DME PAP supplier must discontinue billing Medicare for PAP expenses and the supplier’s notes must reflect that PAP was discontinued.

The PAP supplier’s notes should be included in any denial reconsideration and show that all PAP expenses have ceased. The ordering physician’s treatment notes must document why the Medicare beneficiary failed PAP and show that a valid attempt was made to comply with therapy. The treating dentist cannot provide this documentation, it MUST come from the ordering physician.

What if the patient fails CPAP before Certification?

If the ordering sleep physician determines that the beneficiary has not met the requirements for PAP certification, it is extremely important that the sleep physician’s notes document that the PAP was discontinued and why it was ineffective. A MAD fabricated and delivered prior to the certification of PAP will be paid with no denial. Therefore, it is ideal if the diagnosing physician can determine the most appropriate treatment for the beneficiaries’ SDB as soon as possible to give DSM practitioners adequate time to deliver a MAD within the first 90 days of treatment. Unfortunately, due to scheduling and fabrication time, DSM providers will likely have a difficult time delivering a MAD within the first 90 days of OSA therapy if PAP is dispensed initially. Therefore, most Medicare beneficiaries that are referred for OAT will likely have a claims history which will include a payment for PAP within the last 5 years and OAT denial is likely.

You received your first denial, now what?

Appeal The first level of the appeals process requires that you submit a “redetermination.”

LEGALledger The Medicare redetermination request form is available at https://www.cms.gov/ or on your DME jurisdiction’s website. When filing a redetermination, include as much documentation as you have to support overturning the denial of your claim, such as the physician’s written order, (which must be dated within 6 months of the original face to face office visit pre-diagnosis), the diagnosing physician’s office notes for the face-to-face examination, a copy of the sleep test (PSG or HSAT), PAP prescription, DWO, physician’s office notes regarding PAP failure, PAP discontinuance order, the treating dentist’s clinical intake examination and delivery appointment notes and a copy of the denial. The redetermination must include any and all supporting documentation necessary to prove medical necessity for OAT after DC of PAP. Include the PAP supplier notes if available, to show that PAP expenses are no longer being billed to Medicare. This will show that the beneficiary is not utilizing combination therapy, which would be a violation of Medicare regulations.

Include the physician’s notes to explain any lapse in the continuation of care. For example: (PAP returned 12 months ago and there has been a lapse in treatment). Your dental intake examination and the order sleep physician’s notes should document how the beneficiary’s symptoms have worsened making OAT “medically necessary”.

The more medical justification you provide, the better the chance of overturning the denial. The more time that the rental of PAP is over day 91, the less chance you have of a successfully outcome.

What if the redetermination is denied?

A Level II appeal is your next course of action which is known as a “reconsideration” of the claim. Again, the appeal must be requested in writing and the necessary form can be obtained at https://www.cms. gov/. It is essential to include all supporting documents that you have available. Explain why the denial of your redetermination was inappropriate. The reconsideration request will be reviewed by the qualified independent contractor (QIC) for your jurisdiction.

This is the last level of the appeals process which allows you to submit supporting documentation, therefore, it is imperative to include all the information you have that can support overturning the case.

Advanced Beneficiary Notification (ABN)

Given the system update and restrictions associated with the “Same or Similar” policy, it is vitally important to determine whether the Medicare same or similar restrictions will apply for any Medicare beneficiary. If you determine that a patient’s Medicare claim for OAT will be denied under RUL, it may be advisable to have that patient execute an Advanced Beneficiary Notification (ABN) to inform the patient that their Medicare claim will likely be denied. The ABN places the beneficiary on notice that if the Medicare claim is denied, then they will be personally responsible for the charges for OAT. If you fail to obtain a signed ABN from the patient prior to rendering the service, your practice will not be able to collect any amount due from the patient when Medicare denies your claim. Without a properly executed ABN, the providing dentist cannot charge the beneficiary for the OAT. Let me repeat that, with emphasis: Without a properly executed ABN, the providing dentist cannot charge the beneficiary for the OAT. Therefore, a signed ABN may be useful when a RUL denial is expected. A denial should be expected when a Medicare beneficiary is referred for OAT and there has been more than 91 days since the beneficiary was placed on PAP. Participating and non-participating Medicare suppliers should execute an ABN prior to impressions when a Medicare denial is anticipated. When presented with the probability of a denied Medicare claim, the beneficiary can make an informed decision.

Unfortunately, if an ABN is signed, the appropriate modifier must be used when filing to inform Medicare that an ABN has been executed. This

Redetermination Checklist ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍ ❍❍

❍❍

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Date of Physician Face-to-Face Visit Date of Diagnosis Date PAP therapy started Physician’s written order, (which must be dated within 6 months of the original face-to-face office visit pre-diagnosis) Diagnosing physician’s office notes for the face-to-face examination Copy of the sleep test (PSG or HSAT) PAP prescription DWO Physician’s office notes regarding PAP failure PAP discontinuance order Treating dentist’s clinical intake examination Delivery appointment notes Copy of the denial Any and all supporting documentation necessary to prove medical necessity for OAT after DC of PAP PAP supplier notes, if available, to show that PAP expenses are no longer being billed to Medicare Physician’s notes to explain any lapse in the continuation of care. For example: (PAP returned 12 months ago and there has been a lapse in treatment) Your dental intake examination and the order sleep physician’s notes should document how the beneficiary’s symptoms have worsened making OAT “medically necessary” Any additional documentation

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LEGALledger act ensures that your Medicare claim will be denied and makes a reversal of this denial more difficult. When submitted with the appropriate ABN modifier, Medicare is placed on notice that “the supplier feels the item will not be a covered service and the beneficiary has been informed of this fact and understands why the item will not be a covered by Medicare.” Refer to the LCD for more information regarding correct coding for oral appliances that do not meet Medicare guidelines.

If an ABN is on file and the office is instructed to submit to Medicare, when the claim is submitted correctly the resulting denial will indicate that the beneficiary is responsibility for the charges. Providers should be aware that they are then required to collect the fee that was submitted. (i.e. if you file for $6500.00, you are required to collect that amount).

If the beneficiary is willing to forego filing the claim to Medicare, a cash discount may be possible. The patient becomes a cash patient when an ABN is executed with option B selected on the ABN document. The patient must understand why no Medicare coverage is expected and that you will not file a claim with Medicare for the OAT. Under that scenario the patient becomes a cash pay patient and could be offered an appropriate cash discount.

Extra Tip: Most offices are unaware that some medical insurance companies may refuse to allow you to collect from a patient on denied claims if you are in-network. Therefore, prudent practitioners may want to start utilizing an advanced patient notice for services that a private payer might not cover. Some payers will accept the Medicare ABN, but some have their own form. If you are in-network with one or more medical insurance companies, you should check with those payers and see if they have an ABN-type notice for your use. It is important to understand you cannot use an ABN for every patient – this is considered a ‘Blanket ABN’ policy and renders ALL ABNs on file ‘null and void.’

What if a physician orders OAT as the first line of treatment and it is not effective?

If OAT is the first line of treatment, the ordering physician is responsible for evaluating and documenting the effectiveness of the therapy. Once the sleep physician determines that OAT is inadequate, PAP may be ordered if the beneficiary qualifies under LCD L33718. Again, a claim for PAP will automatically be denied as not reasonable and necessary when submitted.

The PAP will be classified as “same or similar treatment within the 5-year RUL”. Timing is of the essence, however, if PAP is initiated immediately after failing OAT, the denial would have the possibility of being overturned at first level appeal. PAP will always receive preferential treatment.

Why wasn’t the dental sleep medicine community notified?

Medicare jurisdictions are continually updating their systems, since there was no policy change, no notification was required. Same or similar/ RUL has been in place since 2001. This is not a new policy; the system was just updated to apply to CPAP and OAT.

Conclusion

Once diagnosed with OSA, the treating physician has the option of choosing what therapy is best for that beneficiary. Commonly, sleep physicians prescribe PAP as first line therapy. Once PAP is dispensed, there is a 90-day certification period where the beneficiary must document usage of 4 hours per night for 21 nights in any 30-day period during the first 90 days of treatment. If the beneficiary satisfies these requirements, the sleep

62 DSP | Winter 2018

The question is whether you require an ABN before you treat a Medicare patient.

physician will certify that the beneficiary has been successful, and Medicare will pay for the PAP. If the beneficiary does not qualify for PAP during the 90-day certification period, Medicare will not reimburse for the PAP and the beneficiary is eligible for benefits for an OA. If your patient has utilized PAP therapy more than 90 days, your Medicare claim for OAT will be denied. However, on appeal, you have a reasonable chance of receiving payment, if and only if, you have followed Medicare rules to the letter and you provide the necessary documentation on appeal to prove that ALL the rules have been followed AND there is no way for the patient to wear CPAP. The problem is that the time and effort required to secure the documentation and file the appeals puts an amazing amount of work on your billing team. In my office, we are currently too busy to appeal each Medicare claim.

The more difficult question is whether you require an ABN to be executed before you treat a Medicare patient. We live in an affluent area where the majority of Medicare patients can proceed with treatment when required to pay cash. However, if you initiate this policy, a significant portion of your Medicare patients may be unable to finance treatment. Additionally, if the patient signs an ABN, CMS regulations require that you must use the appropriate modifier to designate that you have an ABN on file and any appeal of the resultant denials are almost always unsuccessful.

It is equally important to inform your referring physicians of the consequences of this update and how it will affect their patients. Here is some possible good news: DSM may have received an unexpected benefit because of the March update. It may be easier to document that OAT is ineffective than document the ineffectiveness of PAP. Therefore, under RUL, OAT may be the best choice as first line therapy for mild to moderate cases. A discussion with your referring physicians could prove beneficial to your DSM practice.

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SLEEPhumor

...The Lighter Side of Sleep Apnea

64 DSP | Winter 2018

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